The Journal of
Obstetrics & Gynaecology
of the British Empire
VOL. 45, No. 3 NEW SERIES JUNE, 1938
Urinary and Faecal Fistulae*
BY
*NAGUIB PACHA MAHFOUZ,
M.Ch. (Cairo), M.R.C.P. (Lond.), F.C.O.G.,
Professor of Obstetrics and Gynaecology, Faculty of Medicine,
Cairo; Gynaecological Surgeon to Kasr-El-Aim Hospital, and
to the Kitchener’s Memorial and the Coptic Hospitals.
FISTULOUS communications between the genital apparatus and
the adjacent organs, the bladder and rectum, are among the
most troublesome, depressing and deplorable diseases women
are liable to suffer from. For several generations our prede-
cessors have, with infinite never-flagging patience searched out
new methods for curing these hitherto inoperable infirmities,
when one by one the older methods proved themselves useless.
Such a noble struggle was bound to succeed and the insult of
the ages was wiped out. In a previous communication*®® | dealt
with the history of faecal fistulae. I shall, therefore, confine
myself to a short review of the history of urinary fistulae and a
few remarks on the subjects of urinary and faecal fistulae.
Historical. There can be no doubt that urinary fistulae
existed from time immemorial. In the Ebers papyrus several
prescriptions are given for the cure of incontinence of urine in
women. Professor Derry, of the Faculty of Medicine of Cairo,'
discovered a large vesico-vaginal fistula in the mummy of a
dancing girl, in all probability a negress in the court of Mentu-
hotep of the Eleventh Dynasty who reigned about 2050 B.c.
Professor Derry, to whom I am indebted for permission to
publish Plates I and II of this mummy, describes the pelvis to
be dolicopellic and considerably contracted in its transverse
* Lecture delivered at the Hammersmith British Postgraduate School.
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diameter. ‘‘Even in the present dried-up condition of the
parts,’’ he goes on to say, “‘it would be difficult for a foetal head
to pass through, and there seems every probability that the
severe damage discovered was brought about at the time of
parturition, with the subsequent death of the woman.”’
When I examined the mummy I found, besides the large
vesico-vaginal fistula described by Professor Derry (Plate I) a
complete tear of perineum (Plate II).
It is rather remarkable that a lesion so palpable, with
symptoms so obtrusive as a urinary fistula, should pass unnoticed
by Greek and Roman writers. The first mention of a fistula in
literature is found in a passage in Al-Kanoun by Ibn Sina, the
distinguished Perso-Arabic physician,” known to the Europeans
under the name of Avicenna. This great observer not only
mentions the occurrence of urinary fistulae in women but also
states that they may occur as a sequel to difficult labour. He
further tells us that the condition is incurable and remains so
till death. References to fistulae in European literature com-
mence about the end of the sixteenth century. In 1597 Plater®
gave the following clear description: ‘‘As a consequence of a
difficult first labour, a young country girl had the opening of the
bladder rent to such a degree that there was a long, gaping
furrow in its place, and the open bladder could be seen... On
account of this injury there is a constant involuntary discharge
of urine, and the surrounding parts have become excoriated and
inflamed.”’
In 1762 Roonhuysen,‘ of Amsterdam, first described, and
probably put into execution, a well-defined plan of operative
treatment. He exposed the fistula by a speculum, pared the
edges, and brought them together by passing through them pins
made of sharpened quills of a swan, held in place by red-waxed
silk threads wrapped round their edges. Dressings made of flat
wicks moistened in warm balsam oil were then applied, and the
vagina filled with suitable sponges moistened in a little oil of
sweet almonds. This achievement may rightly be considered as
the first milestone in the operative treatment of urinary fistulae.
In 1752 Johannes Fatio® (quoted by Miller*) spoke of pulveriz-
ing live toads in a new pot, the product to be placed in a bag
and worn round the abdomen as a method of treatment, but
stated that he preferred surgical methods, and mentioned curing
several fistulae by the Van Roonhuysen technique.
Jobert de Lamballe,’ in 1862, was the first operator who
systematically treated a large number of urinary fistulae, and
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URINARY AND FAECAL FISTULAE
many of them successfully. He planned a method of operating
which consisted in pulling the cervix down by traction with
forceps, a thorough denudation of the edges of the fistulae, and
an exact approximation by interrupted sutures. In difficult cases
he practised incising the lateral vaginal walls. If the cervix was
found implicated he advised liberating it from the bladder by a
transverse incision in the vaginal vault. Lamballe was probably
the first surgeon who recognized the importance of avoiding
tension when operating on fistulae.
In the same year (1862) Marion Sims, of Alabama,* working
independently in America, published a method by which he cured
230 cases out of 312. He exposed the fistula by a duck-bill
speculum which he had invented, pared the edges of the fistulae
in a funnel form down to, but not including, the vesical mucosa.
He then brought the edges of the wound together by wire sutures
which were carefully inserted at suitable intervals, and secured
the sutures with clamps which consisted of two parallel bars.
Silver-wire, which was undoubtedly a great improvement on un-
sterilized silk which was used at that time, was not an innovation
with Sims. Luke,’ of Charing Cross, used it in closing fistulae
in 1850, but Sims has the credit of popularizing its use in
America. In Great Britain two contemporaries of Sims, Baker
Brown"’ and Simpson” obtained marked success in the treatment
of fistulae using silver wire and devising several new instruments.
Though Sims’s method has shown unmistakable signs of falling
into disuse, owing to the advent of better methods, it has still
some admirers. Foremost amongst these is Herbert Spencer,’® in
London, who employed this method exclusively for 38 years and
obtained excellent results, using a hollow needle which he devised
for the introduction of the silver-wire sutures.
The flap-splitting operation. Sanger,’* Martin,’* and others
are considered to be the originators of the ingenious flap-splitting
operation; but in my opinion Maurice Henry Collis, of Dublin,
should be recognized as the first surgeon who employed this
method, since a few years before Sanger and Martin published
their method Collis'* published in the Dublin Medical Journal
his method of closing fistulae by a flap-splitting operation which
he had been practising for several years. The following extract
from his paper describes the details and emphasizes the merits of
the procedure :—
The operation consists, first, in splitting the margin of the fistula all
round, so as to separate the vesico-vaginal septum in two equal portions,
one half consisting of the vaginal mucous membrane and submucous
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tissue, the muscular portion of the septum being equally divided between
the two. The extent of this artificial separation is to be regulated by the
extent of the fissure, by the condition of the margins and, to a certain
extent, by the position of the fissure. Where the fissure is near the vesical
end of the urethra, or near the cervix uteri the dissection need not be
carried to any great depth.
Anyone who has removed a ring of mucous membrane from ever so
small a fistula will have observed how large it becomes under the process,
and sooner or later will have probable cause to regret the loss of substance
thus entailed; whereas, in my operation, if it fails, it leaves the patient in
no worse condition for subsequent treatment than before.
The operation is simple and requires no very complex armamentarium
and only the amount of dexterity which should be possessed by every
surgeon deserving of the name, for it is not so much the implement as the
hand that guides it which secures success, and all surgeons ought to be
able to do their work with as few implements as possible.
My operation is suitable to almost every case, and to many cases which
could not be subjected to the older methods with the smallest chance of
success. In large gaps, where the loss of substance is to be measured by
square inches, no person could expect union by simply paring the edges
and drawing them together by interrupted sutures. The strain on the
threads would be too great, and they would inevitably cut out. Nor is
the success of autoplastic operations, by which flaps are transplanted from
neighbouring parts, such as to lead us to expect much from them. In
these cases it is of great importance to have a mode of operating which
can be frequently repeated without repeated diminution of the already
scanty material.
In small gaps, on the other hand, it will not redound to the credit of
the operator if the rent is made worse each time he interferes. Such a
misfortune cannot happen by my operation in any case to which it is
suited. There is no loss of substance; and the surgeon can begin again
de novo in a few weeks with parts in at least as favourable a position
as before.
It is remarkable that Collis’s method is not to be found
described in any of the English or American textbooks, except
that of Lawson Tait'® published in 1889. Lawson Tait adopted
and popularized Collis’s method and seems to have had great
success with it. The following whimsical passage quoted from
his book gives you an idea of the number of cases of urinary
fistulate that passed through his hands:
I have already said that operations for vaginal fistulae are rarely paid
for, except in gratitude, because the patients are nearly always poor.
I must have operated on two or three hundred cases, and I have not yet
been remunerated to an extent which would pay for the instruments I have
bought for the purpose.
In 1890 Trendelenburg’’ made a radical departure from all
the foregoing methods by opening the bladder suprapubically,
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URINARY AND FAECAL FISTULAE
freeing the bladder wall all round the fistula and closing the
defect with catgut. Three years later Von Dittel'* opened the
peritoneal cavity, detached the bladder from the uterus, and
closed the fistula by catgut.
The year 1894 showed a great advance in the operative tech-
nique for the cure of fistulae, when Mackenrodt'® developed
Collis’s operation and practised wide separation of the bladder
from the vaginal walls on all sides prior to suturing each layer
independently. All later techniques are simply modifications of
Mackenrodt’s operation adopted to suit the different types of
fistula.
Aetiology. The overwhelming number of fistulae met with
in Egypt is a sequel to neglected labour. Thanks to the more
expert obstetrical practice in England, I understand that there
are but few fistulae resulting from bad midwifery at the present
day, as compared with the days of Lawson Tait. When I started
practice in Egypt in 1902 the practice of obstetrics was in a truly
vexing state. There were not any maternity hospitals in our
country, and the training of midwives was extremely defective.
It, therefore, cannot be wondered at that in 30 years I had to
operate on more than 400 cases of urinary and 75 of recto-
vaginal fistulae. In my section of Kasr-El-Aini Hospital a
special ward of ro beds is reserved for the treatment of such
cases.
To-day, thanks to the steps taken by the Faculty of Medicine
and the Ministry of Public Health, Egypt can compare most
favourably with many European countries. As a result of such
efforts the number of cases of fistula admitted into my special
department is decreasing very rapidly. In fact the patients who
are now admitted come from the sparsely populated and out-
lying districts of our own and the neighbouring countries.
The process by which a fistula develops after labour is the
following. When labour becomes difficult, on account of dis-
proportion between the pelvis and presenting part, or when the
presentation is abnormal, the uterine contractions increase in
strength and endeavour to force the presenting part through the
brim. The membranes protrude unduly in the vagina, and
premature rupture occurs. In consequence of early rupture and
disproportion the full force of the uterine contractions is directly
exerted upon the foetus and the presenting part is forced against
the brim of the pelvis or gets tightly impacted therein. The
vesico-vaginal septum, and the cervix if the latter is not dilated,
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will be tightly compressed against the back of the symphysis
pubis. The uterus in such cases usually passes into a state of
tonic contractions which prevents any remission in the pressure
exerted on the soft parts. As a result of the continued pressure
the tissues undergo necrosis and slough away. The duration of
compression in such cases is usually very long, but I have seen
cases in which a fistula developed after 3 hours of compression
only. At about the fifth day of the puerperium the slough
begins to separate and urine dribbles involuntarily into the
vagina (Figs. 3 and 4).
The process just described accounts for the majority of fistulae
which occur as a result of labour; but fistulae following labour
can also result from direct injury received during the operative
procedures used for delivery. The perforator may slip and
perforate the vesico-vaginal septum. Moreover, in a difficult
delivery with the forceps, or during the operation of craniotomy,
the vagina and cervix may be nipped between a blade of the
forceps or cranioclast and the symphysis pubis so that the bladder
may be cut through, or crushed to such an extent that sloughing
results during the puerperium. (Figs. 5 and 6). Such injuries
to the bladder are more liable to occur when the important pre-
caution of emptying the bladder before the application of such
instruments is forgotten.
The situation of the fistula depends to a great extent on the
state of the cervix, when impaction and compression occur, and
also on the plane of impaction. If pressure and compression
occur before the cervix is pulled up over the head, the vault
of the vagina and the cervical tissues may be involved in the
slough. The resulting fistula will be vesico-cervico-vaginal, or
uretero-vaginal, as the case may be. The prevailing opinion is
that in protracted labour uretero-vaginal fistulae cannot be caused
by direct compression during childbirth on account of the upward
displacement of the ureter above the brim of the pelvis. I am
now convinced that this is not the case.
To verify the accuracy of this opinion I dissected the bodies
of 10 women who died undelivered as a result of rupture of the
uterus. In most of these women I found the trigone of the
bladder, and the parts of the ureters which lie within the wall
of the bladder, subjected to direct compression against the
symphysis pubis (Figs. 7, 8, 9 and 10), as well as that portion
of the urethra leading from the bladder. This compression was
particularly marked in a case in which the cervix was not entirely
effaced and retracted and in which the slough included a good
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URINARY AND FAECAL FISTULAE
portion of the ureter (Figs. 3 and 4). Another misconception is
that urethro-vaginal fistulae are among the rarer varieties, and
this I formerly believed. The explanation given was that com-
pression usually occurs at the brim of the pelvis and that the
urethra lies too far down to be compressed. In order to verify
the truth of this statement I have carefully examined roo patients
suffering from what was termed vesico-vaginal fistula during the
last 10 years. I found by careful examination and measurement
of the urethra that the sloughing which ultimately led to the
formation of the fistulae had in more than half the cases involved
from one-third to half of the urethra. This is not to be wondered
at, since in most cases of obstructed delivery in which the bladder
is pulled up above the brim of the pelvis the urethra is pulled
up with it. If the seat of obstruction happens to be at the brim
of the pelvis, the neck of the bladder and a small portion of the
upper third of the urethra seldom escapes compression. In cases
in which the presenting part is impacted in the cavity of the
pelvis, or detained at the outlet, the entire urethral canal will be
lying in the plane of compression. In some of these cases the
urethra sloughs away completely.
In a certain number of cases annular sloughing of the neck
of the bladder occurs. In these cases the internal orifice of the
urethra is always blocked and the urethra is separated from the
remaining portion of the bladder by dense scar tissue. In some
cases of neglected delivery, in which the patient was left un-
delivered for several days, the vaginal canal sloughed away
completely and was replaced by a narrow gap surrounded by
scars and pervaded by fistulous tracts.
Pressure necrosis, as I have just said, has accounted for the
greater number of fistulae with which I have had to deal, but
other causes may be responsible for this occurrence, such as
lacerations produced in labour, perforation by instruments, and
malignant ulcerations (Fig. 11). Trauma caused by falls on
pointed objects accounted for a few cases. Roughness on the
part of the husband in attempting to force an opening into the
vagina in newly married girls accounted for 10 cases in our
series. Some of these girls had vaginal atresia. Their husbands,
unaware of this fact, had persisted in their attempts until they
had forced an entrance. In some patients the hole thus made
opened into the bladder, resulting in a vesico-vaginal fistula,
while in others it opened into the rectum. Thanks to the new
law which has been passed in our country the lowest age in
which marriage is allowed is 16 years, and so such cases have
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ceased to appear. Among the causes which are becoming more
common may be mentioned ulcerations due to radium and
injuries following surgical operations, such as anterior colpor-
rhaphy, and total hysterectomy, and other complicated pelvic-
abdominal operations. The bladder or ureter may be injured,
or their blood-supply interfered with, leading to sloughing of the
tissues and the formation of a fistula. In many countries the
great diminution in the number of fistulae due to faulty obstetrics
has almost been balanced by a higher incidence of cases due to
surgical operations. In 1909 Sampson’ reported 19 accidental
injuries to the ureter in 156 hysterectomies for carcinoma of the
cervix. Judd,” in 1920, reported 50 cases of urinary fistulae as
a sequel to surgical operations at the Mayo Clinic between 1908
and 1919. Bland,” in 1925, collected from literature 441 cases
following operations; of these 81 were bilateral. IIl-fitting pes-
saries, calculae and foreign bodies introduced into the vagina
are amongst the rarest causes. Fig. 12 is an instance of this
kind. A young girl of 9 years of age managed to introduce into
her vagina a fibre basket. Vaginitis followed and persisted. The
basket ultimately perforated the vesico-vaginal septum. The
resulting fistula was one of the worst I ever had to deal with.
Bilharziosis, which accounts for 99 per cent of urinary fistulae
in men, is the rarest cause in women. In our series of 400 cases
it accounted for less than I per cent. (Fig. 13). Two of our
fistulae were congenital in origin. Figs. 14 and 15 illustrate an
extremely rare cause. Complete inversion of the bladder
occurred in the course of an otherwise normal labour. The
urethra was torn right through. This led to incontinence of
urine which necessitated ultimate repair of the torn urethra.
Vaginal fistulae may be central or lateral, mobile or im-
mobile. Some are tethered to the pelvic brim, and if small are
difficult to see. Some fistulae lie concealed in scar tissue and
thus escape notice. Multiple fistulae are sometimes met with. I
have recently operated on a patient who had a uretero-vaginal
fistula situated high up in the vault, and another fistula—a
urethro-vesico-vaginal—low down. The edges of the fistula may
be thick, or thin and sharp.
The size of a fistula varies from a tiny hole which will hardly
admit a bristle, to a large gap caused by total destruction of the
base of the bladder and the vesico-vaginal septum. (Fig. 16).
In many patients the cervix and vault of vagina had sloughed
away completely, leaving in their place a mass of dense scar
tissue surrounding a big hole in the bladder. In many cases of
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URINARY AND FAECAL FISTULAE
this kind one can see the ureters opening directly in the vagina
or near the edges of the fistula quite easily.
Fig. 17 showed a condition which is sometimes seen in those
cases in which the fistula is large. The fundus of the
bladder is everted through the fistula. The mucous membrane
is oedematous, rugose, deep red in colour, and encrusted with
phosphates.
Symptoms and diagnosis. The first symptoms appear during
the puerperium in the form of difficulty and pain in urination.
Blood and mucus soon appear in the urine, as well as other
signs of cystitis. In most of the patients febrile disturbances and
signs of general and local sepsis develop during the puerperium.
Incontinence appears as soon as the slough begins to separate.
This usually takes about a week. If the fistula were due to lacera-
tion or perforation by instruments, or trauma, incontinence will
naturally appear immediately.
Incontinence of urine following labour is not always due to
fistulae. In some cases it is the overflow resulting from over-
distension of the bladder with urine, or it may result from
imperfect control due to a relaxed sphincter. After difficult
instrumental labour a certain amount of dribbling may occasion-
ally occur but disappears in a few days. On the other hand, a
fistula may be present, and yet the patient, if her perineum is
intact, may retain a considerable amount of urine in the vagina,
giving the obstetrician an erroneous idea that the bladder is
continent.
The constant dribbling of urine in the vagina, and out over
the vulva, perineum, and adjacent parts, will soon show its
effects. A painful dermatitis with excoriations will appear both
within the vagina and outside it. These excoriations will, if
not properly treated, soon become infected. The vulval hairs
will be covered by incrustations, and small ulcers will form at
their bases. As a consequence of this the parts affected become
exquisitely tender (Fig. 18).
The effects of urinary fistulae on the general health and
morale of the patient are often very marked. The constant
urinous smell emanating from the patient makes her offensive
to herself and to others and may impel her to live a solitary life.
Diagnosis. The diagnosis of a fistula is usually very easy.
The hole can be palpated by placing a finger in the vagina and
introducing a sound into the bladder through the urethra. The
tip of the sound can be passed through the fistula to meet the
finger in the vagina. With a speculum the urine can be seen
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dribbling from the fistula. It is only small fistulae which lie
concealed in scar tissue and vesico-cervical and ureteral fistulae
which cause difficulty in diagnosis. In such cases we inject the
bladder with a coloured solution and watch the flow of the
injected fluid through a speculum. If the bladder is involved
the fluid will be seen flowing through the fistula into the vagina
in cases in which the fistula is vesico-vaginal, or through the
cervix if the fistula is vesico-cervical. If, on the other hand,
the fistula is ureteral and the bladder is not involved, fluid will
not come out of the vagina or cervix. In diagnosing these
ureteral fistulae the cystoscope is of great help.
The following associated conditions should always be care-
fully noted :—
1. The size, situation and form of the fistula.
2. The presence of more than one fistula.
3. Whether the fistula is mobile, or fixed by scar tissue, or
anchored to the bony pelvis at any point.
4. The permeability of the internal orifice of the urethra.
5. Location of the ureteral orifices and their relation to the
edges of the fistula.
6. In fistulae involving the vault of the vagina and cervix
the external os should be carefully located.
7. The presence of associated complications, such as rectal
fistulae, parametritis, perimetritis, salpingitis, and other inflam-
matory lesions of vagina and perineum.
Treatment. An attempt should not be made to close a fistula
until all raw granulating surfaces are quite healed up and com-
plete involution of the pelvic organs has occurred. The urine
should be free of albumin and pus. If the parts are inflamed
or ulcerated, the vulva and perineum should be constantly
covered with a thick layer of an ointment of paraffin-zinc-oxide
to prevent contact with the leaking urine. A patient should not
be operated upon unless her general condition is good, her renal
functions normal, and all local inflammatory conditions have
disappeared. The best time to operate, provided that the genera]
and local conditions allow it, is 2 months after labour. Nature
is thereby given ample time to effect a spontaneous cure, if such
a cure is possible. I have seen holes so large that they would
admit two fingers and which healed spontaneously in less than
2 months. Prof. Gray Turner, in a letter to the writer, sug-
gested that nursing such patients lying on their face would, in
all probability, greatly facilitate a spontaneous cure.
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URINARY AND FAECAL FISTULAE
Anaesthetic. Stovaine intra-thecal anaesthesia is ideal when
operating on a urinary fistula. The perineum gets very lax and
can be more easily depressed than is possible with any other
anaesthetic. The patient is placed in the exaggerated lithotomy
position and the posterior vaginal wall depressed by a speculum.
In certain cases small wire speculae are used to separate the
lateral sides of the vagina. If the cervix is found mobile it may
be pulled down with a tenaculum forceps displacing the fistula.
Unfortunately, this is seldom possible, the mobility of the cervix
being, in most cases, very limited. The fistula can, however,
be sufficiently brought into view by drawing it down with a
tenaculum forceps applied to the vaginal walls at a distance of
I centimetre from the upper and lower edges. If this cannot
be done the operation becomes very difficult. It needs years of
experience to enable the surgeon to tackle immobile fistulae of
the vault. Inaccessibility of a fistula is not always due to its
immobility. In some cases it is caused by stenosis of the vagina
by cicatrices. This difficulty can, however, be easily overcome
by making lateral vaginal incisions. In bad cases a Schuchardt
incision may be found necessary. (Figs. 19 to 22 show the
steps of the operation in a case in which the fistula was concealed
and made inaccessible by a ring of cicatrical tissue in the lower
third of the vagina.) The first step (Fig. 19) is to make a lateral
vaginal incision to break the continuity of the cicatrical ring
and to widen the vagina. The second step (Fig. 20) is to sepa-
rate the vagina from the bladder by a circular incision. From
this incision two short longitudinal incisions are carried: one
upwards towards the cervix and the other downwards towards
the meatus. A catheter or male sound passed into the bladder
through the urethra and pushed beyond the lower edge of the
fistula acts as a counterpoint and facilitates the differentiation
between bladder and vaginal walls. In Fig. 21 the bladder wall
has been carefully dissected from the vagina. In bigger fistula
this separation should be carried much wider than is shown in the
figure. In some extensive cases this separation should be carried
upwards as far as the vesico-uterine peritoneum, downwards not
very far from the meatus, and laterally so far as can be
managed. Mobilizing the bladder flaps is the most important
step of the operation. It greatly facilitates subsequent approxi-
mation and suturing of the bladder walls without tension on the
sutures. The sutures should include a good bite of tissue but
should neither perforate the bladder nor include the mucous
membrane. If the ureteral orifices are found at or near the
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margins of the fistula the sutures should be applied in such a
manner that the ureteral orifices are turned up into the newly-
formed bladder when the sutures are tied. It is generally
recommended to pass the middle sutures first, but I find it much
easier and safer to pass the lateral sutures first. One then has a
better view of the tissues one is suturing, and there is less likeli-
hood of including a ureter which may be lying near the edge of
the flap. When the sutures have been tied the permeability
of the bladder should be tested. If no leak is discovered, the
vaginal flaps should be trimmed and brought together by silk-
worm gut sutures. Thinned out vaginal tissues and scars should
be carefully removed from the flaps before the sutures are
applied. The vaginal edges need not be sutured in the same
plane as the bladder, but in whatever plane that will cause less
tension on the sutures when tied. A catheter is kept in the bladder
for 7 days to prevent this organ being distended with urine.
The sutures are removed on the thirteenth day. Buchu and
hyocyamus mixture and urotropin are given to the patient during
convalescence.
The above-mentioned technique can be modified to suit all
different types of fistulae.
In vesico-uterine fistulae, for instance, the cervix should be
separated from the bladder up to the level of the fistula. When
that level is reached the cervix should be divided in the middle
line up to the fistula. This will greatly facilitate further dissec-
tion. One can then easily separate the fistula from the uterus
and close it by catgut.
In uretero-vaginal fistulae the ureter is dissected free for a
short distance. The bladder is demobilized sufficiently until the
level of the ureter is reached. An artificial fistula is next made
into the bladder, into which the liberated end of the ureter is
implanted. In difficult cases implantation should be effected by
the abdominal route.
In certain cases a large fistula may almost entirely close, only
a little hole being left which remains patent. Such fistulae are
called residual fistulae. To try and close such a fistula by paring
and suturing the edges, as one is always tempted to do, is mere
loss of time. The edges are usually thin, devitalized, and ill-
adapted for plastic union. The operation is sure to fail. To
effect a cure in such cases all scar tissue should be removed.
When this has been done one finds that the fistula has returned
to its old dimensions. Wide denudation and accurate suturing
should now be carried out in the manner described.
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DIFFICULT AND COMPLICATED CasES.
High fistulae are generally considered the most difficult to
cure. In many cases this is true, and more especially when the
fistula is fixed and the vaginal canal narrowed by cicatrices.
But a high fistula, though difficult to close, once this has been
effected the patient is sure to have complete control over her
bladder. Whereas in urethral defects and in fistulae situated at
the neck of the bladder, though the operative field is more
accessible, greater technical difficulties are met with in order to
secure perfect control. Fig. 23 shows six varieties of these low
fistulae, viz. : —
(a) A urethro-vaginal fistulae, in which the tissues are thinned
out, scarred and ill adapted for plastic union. It is difficult to
dissect a flap, or to evade piercing the mucous membrane when
the sutures are applied.
(b) The floor of the urethra has sloughed away. In such
cases, unless fasicules of the sphincter are discovered and made
use of in forming a new urethra, efficient control is seldom
obtained.
(c) Complete destruction of the urethra. For the treatment
of this condition Kelly suggested making a tunnel under the vesti-
bule and through it drawing a long flap dissected from the anterior
vaginal wall. The base of the flap is left attached to the
vesical opening. By this method, or by that devised by Ward,”
or Farrar, one can succeed in making a canal lined with mucous
membrane; but the urine will dribble through it almost as badly
as it dribbled from the fistula. A little success may be obtained
by placing a mattress stitch of linen at the site of the vesical
sphincter (Kelly), or by lengthening the tube and having its outlet
at a little higher level than normal or kinked over the symphysis
pubis. Nevertheless, a certain amount of incontinence will per-
sist, which becomes more troublesome when the patient is on her
feet.
(d) and (e). Partial or complete sloughing of the trigone. In
these cases separation of the bladder-wall should be such as to
enable the surgeon to bring the bladder-flap to the level of the
urethra so that the latter is not pulled upon when the sutures are
tied.
(f) Annular sloughing of the neck of the bladder. In certain
patients one finds that the neck of the bladder and the lower half
of the urethra have entirely sloughed away. The blind cul-de-sac
of the urethra is seen on one side, and the contracted bladder
on the other, separated from each other by dense scar tissue.
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In cases of this kind one has occasionally succeeded in reuniting
the bladder and urethra. The operation is started by removing
the scar tissue which lies between the urethra and bladder. Next
the bladder is demobilized anteriorly and posteriorly by wide
dissection which is carried up to, but does not include, the
peritoneum. The urethra is then perforated and its wall dis-
sected for a short distance. The last step is to anastomose the
urethra and bladder in the manner seen in Figs. 24 to 26.
If it is found, when the sutures are tied, that the urethra is
subjected to the least tension the sutures should be immediately
removed. The bladder flaps should then be fixed to the pubic
arch as near to the urethra as possible. The remaining hole
may be dealt with at a subsequent opefation. Fig. 27 shows the
result of anastomosis of bladder and urethra in a patient who
died 7 years after the operation was performed.
SUPRAPUBIC ROUTE.
Inaccessible fistulae which cannot be dealt with by the vaginal
route are sometimes cured by von Dittel’s abdominal operation.
The utero-vesical fold of peritoneum is opened. The bladder
is dissected off the uterus and the fistulous openings are closed.
Another method for closing these fistulae is the one devised by
Trendelenburg. The peritoneum is not opened, but the fistula is
exposed by opening the bladder by a transvesical suprapubic
incision. The bladder edges are then temporarily sutured to the
abdominal wall and the fistulous opening liberated and sutured.
For the last 8 years I have not resorted to any of these
abdominal operations. I find the vaginal route safer, and if J
fail to close the fistula by the vaginal route I seldom succeed to
do so by the abdominal.
The abdominal route is generally indicated in fistulae that
are inaccessible vaginally on account of their fixity. It is just in
these cases that the abdominal route offers great technical diffi-
culties. Elevation of the fistula to the level of the abdominal
wall, whether this is effected by means of sutures, or by pressure
from below, is impracticable on account of the density of the
adhesions. Moreover, the difficulty of avoiding the ureters,
when they are implicated in dense scar tissue, is often very great.
INOPERABLE CASES.
In spite of all recent advances in the operative treatment ot
urinary fistulae a certain number of intractable cases remain
inoperable. For the treatment of these cases two operative
418
URINARY AND FAECAL FISTULAE
procedures used to be practised, viz. colpocleisis (Simon)** and
transplantation of the ureters into the sigmoid.
Colpocleisis. This means complete occlusion of the vagina
in such a manner as to throw the vaginal and vesical pouches
into one common cloaca. I have discarded this operation long
ago, aS in most cases the accumulated urine, menstrual blood,
and other vaginal discharges become very foul and lead to an
ascending renal infection. Calculi have also sometimes formed
in the vagina and bladder, which made the life of the patient
extremely miserable. In my opinion patients suffering from in-
operable fistulae should be contented with wearing a rubber
reservoir rather than submit to an operation attended with such
risks.
Transplantation of ureters. Transplantation of ureters into
the sigmoid, while very successful in cases of ectopia-vesicae, has
led to indifferent results when performed for inoperable fistulae.
In all probability this is due to the fact that the trauma, which
was severe enough to produce ‘such extensive sloughing of
bladder and vagina, is likely to have caused a certain amount of
damage to the kidney. Such damage will make the kidney an
easy prey to infection. Whether this is or is not the real ex-
planation, experience has shown that in many cases in which
that operation was done secondary infection of the kidneys fol-
lowed in a comparatively short time. Very few patients survived
the operation for more than 3 years.
Figures 28 and 29 shows a vicious circle of infection in a
case of transplantation. Ascending infection from the bowels led
to pyonephrosis. The pus discharged from the kidney had, in
its turn, caused such an infection of that part of the gut lying
below the anastomosis that the mucous membrane became gan-
grenous. The mucous membrane lying above the anastomosis
was quite normal in appearance. This perfect specimen has
been kindly presented to my museum by my colleague, Dr.
Makar.
The following is a record of some of the causes of failure
which have occurred in my practice.
1. Trauma to the Tissue.
It would be no exaggeration to say that of all plastic opera-
tions performed on the pelvic organs of women the repair of
urinary fistulae stands out as the most delicate and the most
difficult. It demands long experience, dexterity, precision, and
careful attention to a multitude of details. Foremost among the
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causes which lead to failure is traumatizing the tissues while
operating. A certain amount of trauma is unavoidable when the
bladder walls are held during their separation from the vagina.
This can, however, be reduced to a minimum if the edge of the
flap is held by toothed dissecting forceps and not by pressure
forceps. A sharp knife should be used. In suturing the flaps
the smallest round-bodied needle which will hold the catgut
should be chosen. Great care should be taken in pulling the
needles out. The knots should never be tied too tightly and
there should not be any tension on the flaps when approximated.
Moreover, the flaps should not be dissected too thin, otherwise
their blood-supply will be inadequate and the sutures will cut
through them before healing occurs.
2. Eversion of the Edges of the Bladder.
This is liable to occur if the mucous membrane of the bladder
at the edge of the flap is pierced by the needle. This should be
carefully avoided. To ensure inversion of the edges of the
bladder-flaps when the sutures are placed, the needle should
pierce the flaps r or 2 millimetres away from the edge.
3. The Presence of a Dead Space.
This is apt to occur between the two rows of sutures—the
vesical and the vaginal—in cases in which wide separation of
the bladder is found necessary. This can easily be guarded
against if one or two of the vaginal sutures are made to take a
superficial bite of the bladder wall.
4. Over-distension of the Bladder.
In certain cases the bladder may become distended with
blood. This is liable to occur if the surgeon has cut widely
through the mucous membrane of the bladder. In two of my
cases serious haemorrhage, which endangered the life of the
patient, occurred. I had to remove the sutures and clamp the
bleeding spots.
The bladder may also become over-distended with urine if
the catheter gets clogged by the deposition of earthy salts, or by
blood-clots. If this is not discovered and remedied in time,
powerful and uncontrollable expulsive efforts will cause the
sutures to burst. To avoid this accident it is advantageous to
change the catheter whenever the free drainage of urine is inter-
fered with. If signs of mild cystitis appear the bladder should
be irrigated twice daily by boric acid solution.
420
URINARY AND FAECAL FISTULAE
5. The Use of Unreliable Catgut.
An important point is the choice of catgut. It should be ot
moderate thickness, tensile, and hardened to resist absorption
for 30 days. I have once had two successive failures which were
due to early absorption of catgut before the tissues were united.
6. Operating with an Unhealthy Condition of Kidney, Bladder,
and Vagina.
Fig. 18 shows a vulva excoriated and inflamed by the constant
dribbling of urine. An operation performed on such a patient
without preliminary preparation will inevitably end in failure or
septicaemia.
A careful investigation of the efficiency of the kidney should
also be made, including estimation of the blood-urea. Fig. 30
refers to the one fatal case in my series. The patient died of pyo-
nephrosis 2 months after the operation was performed. Her
blood-urea was high and could not be decreased during the pre-
paratory treatment.
RECTO-VAGINAL FISTULAE.
Aetiology. Rectal fistulae have almost the same aetiology as
vesical fistulae. They may occur as a result of trauma in labour,
or as an unfortunate sequel to a vaginal operation. They may
also result from perforation by instruments used to assist delivery
of the child, or by falls on pointed objects. Some cases are due to
malignant, tubercular, or syphilitic ulcerations, while others are
due to the action of radium or long-retained pessaries.
The process by which a faecal fistula forms after labour differs
greatly from that which leads to the formation of a urinary
fistula. Sloughing, due to pressure-necrosis produced by impac-
tion of the presenting part, which accounts for the overwhelming
majority of urinary fistulae, is seldom the cause of faecal fistulae.
It accounted for 2 cases only in my series of 75. (Fig. 31). The
majority of the remaining cases were the result of a complete tear
of perineum which extended into the recto-vaginal septum. The
lacerated edges of the perineum united spontaneously in the
lower part where the tissues were fleshy, but remained ununited
at the upper end where the tissues were thin. (Fig. 32). This
results in a permanent communication between the vagina and
rectum at the upper end of the healed tear. Among the rarest
causes of faecal fistulae I may mention two cases I met with in
which a fistula at the vault of the vagina resulted from sexual
intercourse with children under 10 years of age. (Figs. 33 and 34).
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Treatment. The methods of treatment of faecal fistulae differ
according to their site. If the fistula is situated at the vaginal
outlet, incorporated in or lying immediately above an incom-
pletely healed perineal tear, the perineum should be cut through.
In other words, the recto-vaginal fistula is converted into a com-
plete tear of perineum and is dealt with as such. The vaginal
and rectal walls are next separated from one another by a trans-
verse incision. This separation should be carried well above the
upper edge of the fistula. The rent in the rectum is now care-
fully sutured with catgut. The sutures should not pierce the
mucous membrane of the gut. The next step is to unite the levator
ani muscles in the middle line so that a thick mass of tissue is
interposed between the lines of sutures in the vagina and rectum
respectively. The cut ends of the sphincter should now be very
carefully brought together and the perineum reconstructed in the
usual manner.
In dealing with rectal fistulae situated at a distance from the
perineum the latter should not be cut through. These fistulae
should be dealt with by a flap-splitting operation performed on
the same principles employed in operating on urinary fistulae.
The separation of the rectal from the vaginal wall should be car-
ried until a point well beyond the upper and lower limits of the
fistulae. In rectal fistulae this separation can be effected more
easily, and much more widely, than separation of the bladder in
urinary fistulae.
Superior fistulae. Fistulae situated at the vault of the vagina,
and more especially those in which the cervix is implicated, are
extremely rare (Fig. 34). Until quite a recent date these high
fistulae were regarded as inoperable.
The abdominal route. In 1914 Eden’ succeeded in treating
a case of fistula of the vault by opening the abdomen. He first
removed the uterus in order to gain free access to the fistula
and then separated the rectum from the cervix and vagina and
closed the fistula by catgut sutures. In order to facilitate the
healing of the wound a preliminary left inguinal colostomy was
done 3 weeks before the operation was attempted. Four weeks
after the successful closure of the fistula the continuity of the
pelvic colon was restored. ;
Unaware of Eden’s technique I adopted the transperitoneal
abdominal route in dealing with an inaccessible faecal fistula of
the vault in 1929 at the Kitchener’s Memorial Hospital’* (Fig. 34).
I did not perform a preliminary colostomy, nor did I remove
the uterus. Recovery was uneventful. Last year I successfully
422
URINARY AND FAECAL FISTULAE
performed this operation on another most intractable case at
the Kitchener’s Memorial Hospital.
The vaginal route. Up till recently all attempts to close
superior rectal fistula by the vaginal route ended in failure. The
vaginal route was considered by most writers as ill-suited in
dealing with these fistulae. It was pointed out that freeing the
sigmoid from the pelvic peritoneum was extremely difficult if
not impossible, and that the blood-supply of the drawn down
rectal tube must be interfered with, favouring infection of the
wound and necrosis of the gut.
In 1934°°° I published the account of an operation for the
treatment of these inaccessible vault fistula by the vaginal route.
(Figs. 35 to 38). The first step of the operation consisted of opening
the peritoneum at the pouch of Douglas. This step rendered the
fistula more accessible. I could now pull the fistula down with
Little’s forceps, sufficiently low to separate the rectum from the
peritoneum and the vagina. Additional help was obtained by
inserting a finger in the rectum and hooking the lower edge of
the fistula down. The rent in the rectum was closed with catgut
and that in the vagina with silkworm gut. I have successfully
performed this operation on two cases. Primary union without
suppuration occurred in each.
After-treatment. The diet should consist of lemonade,
orangeade, albumin water and raisin water. Careful preparation
of the patient for a few days prior to the operation saves her
from a lot of discomfort during convalescence. The bowels
should be kept constipated for 5 to 7 days. On the fifth day
castor oil should be given, followed by an enema of 250 c.c. of
warm olive oil. A soap and water enema is given 2 hours later.
It may happen sometimes in cases of inferior fistulae that a leak
occurs during convalescence so that fluid faeces and gas may
pass through the vagina. In the large majority of cases the hole
contracts down and closes spontaneously.
In conclusion, I desire to express my sincerest thanks to my
colleagues, Professor Roy Dobbin (who kindly allowed me access
to his valuable library), and to him and Professor Shafeek Bey
for their courtesy in permitting me to include patients treated in
their wards. I am also indebted to my assistants, Drs. Ismail,
Magdi, Rafla, Sobhy, Roushdy, and Mazhar, and to Drs. Kawab
Nassif and Kamal Ekdawy for their valuable assistance.
My thanks are especially due to Dr. Boulgakow, the able
Curator of the Museum, and his assistant, F. Abadir, for their
423
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valuable preparations and for the zeal and enthusiasm shown
in many directions, and to Mr. Strekalowsky for his beautiful
drawings.
REFERENCES.
. Derry. Journ. Obstet. and Gynaecol. Brit. Emp., 1935, xiii, 490.
. ‘‘Al-Kanoun’’ by Avicenna, 2nd vol., Cairo edition, 579. (Page 580,
Romae, in ‘‘Typographica Medica,’’ mdxciii. Copy in possession of
Professor Roy Dobbin.)
. Plater. Spach: ‘‘Gynaecol. Aregent,’’ 1597.
. Roonhuysen, Henry Van. ‘‘Heelkonstige Aanmerkingenbetr. de
Gebrecken der Vromwen’’ (Amsterdam), 1663. Translated into English
in 1676, Philosophical Transactions, vol. xi, p. 621.
. Amey. Gynecol. Soc., 1912, xxxvii, 3.
. Miller, N. F. Amer. Journ. Obstet. and Gynecol., 1935, xxx, 676.
. Lamballe, Jobert de. ‘‘Traité des fistulaes vésico-utérines et
vésico-utéro vaginales,’’ 1852. Ibid., ‘‘Memoires lu a l’Académie des
Sc.’’, 4.2.1836. Gaz. Med. de Paris, 1836, iv, 225.
. Sims, M. ‘‘On the treatment of vsico-vaginal fistula.’’ Amer. Journ.
Med. Soc., 1852, xxiii, 59.
. Luke, and J. K. Bartlett. Trans. Wis. St. M. S., 1871, 5-67. Quoted by
Miller in Amer. Journ. Obstet. and Gynecol., 1935, xxx, 667.
. Brown, Baker. ‘‘Surgical Diseases of Women’’ (Amer. ed.), London,
1861, pp. II2-174.
. Simpson, Cl. ‘‘Lectures on Diseases of Women’’ (Amer. ed.),
Philadelphia, 1863, pp. 21-40.
. Singer. ‘‘Einiggeschichtliche und technische Bermekungen zur lappen-
perineorrhzphie.’’ Centralbl. f. Gynidkol., 1888.
. Martin, A. Zeitschr. f. Geburtsh. u. Gynikol., No. 19, p. 394.
. Collis. Dublin Med. Journ., May, 1861.
. Spencer, H. Proc. Roy. Soc. Med. (Obstet. and Gynaecol.). Lect. ix,
1916. Ibid., Amer. Journ. Obstet. and Gynecol., 1925, x, 365.
. Tait, Lawson. ‘‘Diseases of Women and Abdominal Surgery,’’ 90-91.
. Trendelenburg. Volkman’s Samml. Klin. Vort., 1890, ccclv.
. Dittel, L. V. ‘‘Abdom. Blasencheidenfisteln operation.’’ Wien. Klin.
Wochenschr., 1893, xxv.
. Mackenrodt. Zentralb. f. Gyniikol., 1894, viii.
. Sampson, John A. Trans. Amer. Gynecol. Soc., 1909, xxxiv, 473.
. Judd. Surg. Gynecol. and Obstet., 1920, xxx, 447.
. Bland, P. B. Med. Journ. and Record, 1925, cxxi, 389.
. Ward, George Gray. ‘‘Destruction of the urethra and loss of vesical
control, etc. Surg. Gynecol. and Obstet., 1934, lviii, 67-69.
. Simon, G. ‘‘Uber Die Heilung der Blasencheidenfisteln,’’ Giessen, 1854.
. Eden, T. W. Journ. Obstet. and Gynaecol. Brit. Emp., 1914, xxvi, 173.
26.
Mahfouz, N. (a) ‘“‘Urinary fistulae in women.’’ Journ. Obstet. and
Gynaecol. Brit. Emp., 1929, xxxvi, 3. (b) Ibid., ‘‘A new technique in
dealing with superior recto-vaginal fistulae.’’ Journ. Obstet. and
Gynaecol. Brit. Emp., 1934, xli, 577.
424
2
5
6
13
14
15
16
17
18)
19
; 20
21
22
23
24
25
PLATES
Illustrating Figs. 1—38
4
Fie.
Mummy oF HENHENIT, WHO WAS EITHER A QUEEN OR A
DANCER IN THE Court OF KING MENTUHOTEP 2050 B.C.,
SHOWING A LARGE VESICO-VAGINAL FIsTULA.
(1) Bladder cavity enormously dilated; (2) Material
used for embalming; (3) Large vesico-vaginal fistula;
(4) Arm of the mummy lying at the side of body.
(With kind permission of Prof. Derry).
Pie: - 2,
PosreRtIoR SURFACE OF THE Mummy oF HENHENIT,
SHOWING A CoMPLETE TEAR IN THE PERINEUM.
(1) Anal opening; (2) Torn perineum; (3) Vagina.
hy
Fics. 2A AND 2B.
Sections 2 and 2p taken from the edge of a complete tear of the perineum near its
rectal end.
(1) Vessels; (2) Fibrous tissue vaculated; (3) Muscular tissue.
|
Le
2
Fic. 3.
Rupture OF THE Uterus AND COMMENCING GANGRENE OF THE VESICO-VAGINAL SEPTUM.
(1) On the anterior surface of the specimen indicates the upper edge of the tear in
the lower uterine segment, while on the posterior surface it marks the position of the
retraction ring; (2) Lower edge of the tear; (3) Bladder; (4) Foetal part bulging through the
tear; (5) The cut edges of the umbilical cord; (6) Dilated lower uterine segment; (7) Sym-
physis pubis; (8) Haematoma in caput; (g) Vagina; (10) Anal opening; (11) Placenta;
(12) Clot of blood.
161 — Mahfouz’s Obst. & Gyn. Museum.
4
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Fic. 4. Fic. 5.
SLouGHep Tisstes Lapovr. Separation of the symphysis pubis caused by rough attempts
at delivery by forceps. As a consequence of this the urethra
(1) Anterior lip of cervix; (2) Bladder; (3) Symphysis. was torn right off the bladder.
Fic. 6.
Destruction of the cervix and vesico-vaginal septum as a
result of sloughing due to obstructed labour.
*
WAR KS
SSS
rts
ra
Fic. 7.
NorMat ANATOMICAL RELATIONS OF THE URETER. ANTERIOR SURFACE.
(1) Extenal iliac artery; (2) Ureter; (3) Ovarian vessels; (4) Fallopian tube and ovary; (5) Uterine artery;
(6) Ureter; (7) Body of uterus; (8) Trigone of the urinary bladder, bristles are placed in ureteric orifices;
(9) Origin of ovarian arteries.
2304 Mahfouz’s Obstet. & Gyn. Museum.
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Fic. 8.
Norma AnatomicaL RELATIONS OF THE UreTER. (Post. SURFACE.)
(1) Ureter; (2) Ovarian vessels; (3) Ovary and tube; (4) Uterine artery; (5) Ureter;
(6) Ant. wall of vagina; (7) Cervix; (8) Site of urethra.
230 a Mahfouz’s Obst. & Gyn. Museum.
%
Fic. 9.
Tue RELATIONS OF THE TRIGONE OF THE BLADDER TO THE Bony PELvis IN A WomAN wHo Diep
UNDELIVERED AS A Resutt oF Rupture OF THE UTERUS.
The symphysis pubis has been pulled down to expose the neck of the bladder which was directly
compressed between the impacted head of the foetus and the bony pelvis. A bristle marks the vesical
orifice of the ureter.
(1) Symphysis pubis; (2) Urinary bladder; (3) Round ligament of uterus; (4) Fundus of uterus;
(5) Ovary; (6) Ureter.
151 Mahfouz’s Obstet. & Gyn. Museum,
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Fic. 10.
ANATOMICAL RELATIONS OF THE URETERS TO THE Bony PELvis IN A Cask IN WHICH RUPTURE OF THE
Urerus occurred As A Resutt oF Osstructep DELIvERY.
Rupture of Uterus.
The specimen was removed post-mortem from a patient who died as a result of difficult labour. The
child presented by the head; but owing to pelvic contraction natural delivery was impossible. The lower
uterine segment is seen to be greatly distended. The contracted upper uterine segment lies completely
above the buttocks. The foetus, in other words, is entirely surrounded by the distended vagina and lower
uterine segment.
A vertical tear is seen in the left postero lateral side. The placenta was partially extruded into the
peritoneal cavity through this rent. The shoulder and arm of the foetus filled the rent and prevented the
occurrence of any appreciable intraperitoneal haemorrhage.
The trigone of the bladder with the ureteric openings were in the direct plane of compression.
(1) Symphysis pubis; (2) Round ligament of uterus; (3) Retraction ring; (4) Placenta; (5) Umbilical cord;
(6) Foetal head; (7) Ureter,
151 Mahfouz’s Obstet. & Gyn. Museum,
A
:
ONY
j
18.
CANCER oF CERVIX ULCERATING INTO THE BLADDER AND CausinG A Urinary FIstuta.
(1) Cancerous growth ulcerating into the bladder; (2) Walls of bladder; (3) Rectum;
(4) Vagina; (5) Urethra.
439 Mahfouz’s Obst. & Gyn. Museum.
Grew
:
Fic. “22:
A small basket made of interwoven fibres which measured 7 cms. x 4.50 cms. when
dried. Calcareous incrustations are seen desposited upon several parts of the basket.
A young girl of 10 years managed to introduce this basket into her vagina. It was left
there for several months, during which time it ulcerated through the vesico-vaginal septum
causing a large fistula. The hymen was not torn.
1
Fic. 13.
Vesico-VAGINAL FistULA DUE To BILHARZIAL ULCERATION.
(1) Bilharzial papilloma of bladder extruded through the fistula; (2) Cystocele; (3) Site
of fistula; (4 and 5) Bilharzial papillomata of clitoris and vulva.
a
7
5
Fic. 14.
Complete inversion of the bladder which occurred in the course of an otherwise normal
labour.
-
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4
a
4 a ‘
Fic. 15.
Laceration of the urethra caused by complete inversion of the bladder which occurred
in the course of an otherwise normal labour.
Ae
fhe
4
Fic. 16.
TortaL Destruction oF THE VeEsIco-VAGINAL SEPTUM. THE FuNDUs oF THE BLADDER IS
PropLaPsED THROUGH THE GaP.
(1) Prolapsed fundus of bladder; (2) Posterior vaginal wall; (3) Scar tissue in the site
of the sloughed urethra.
4
Vesico-vaginal fistula
Fic. 17.
Larce Vestco-URETHRO-VAGINAL FIsTULA.
The fundus of the bladder is extruded through the fistula, forming an oedematous
rugose, swelling, deep red in colour, and incrusted with phosphates.
j
—-
}
Vesico-vaginal fistula
Fic. 18.
Vesico-VAGINAL Fistuta. VUuLVITIS.
The constant dribbling of urine has irritated the vagina, vulva, and perineum, leading
to dermatitis, followed by incrustation of the vulval hairs with calcareous deposits.
‘
is
Fic. 19.
Vesico-VAGINAL FistuLA RENDERED INACCESSIBLE BY A RING OF CiIcaTRICIAL TISSUE WHICH
NarroweD THE LowER THIRD OF VAGINA
First step of operation. The continuity of the ring is broken through
by making a deep lateral incision.
(1) Vaginal outlet narrowed by scars; (2) The lateral incision; (3) Meatus urinaris,
—
A.
2
aN
Fic. 20.
VESIGO-VAGINAL FISTULA.
Second step. The circular incision which separates the bladder from the vagina. Note the
upper and lower limbs which are made in order to facilitate separation.
(1) The lateral incision; (2) The beak of the sound pushed beyond the edge of the
fistula in order to facilitate differentiation between vaginal and vesical walls; (3) The
incision which separates the bladder from vagina; (4) Sound introduced into the urethra,
4
4
ae
SG
:
Fic. ar.
VesiIco-VAGINAL FIstua.
Third step. The method of suturing the bladder edges.
(1) Bladder wall; (2) Vaginal flap; (3) Incision in the lateral wall of vagina.
(7
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=
'
Fic. 22.
Vesico-VAGINAL FistULa.
Fourth step. The vaginal sutures. The edges of the incision in the cicatricial ring are
sutured in a manner that ensures permanent widening of the vagina.
(1) Meatus urinaris; (2) Vaginal flap: (3) Bladder wall; (4) The lateral incision sutured,
WES
/ a
\
|
a
Urerurat INjurtEs DUE TO SLOUGHING.
(1) Urethra-vaginal fistula. Efficient sphincteric action can be attained when the fistula is
repaired.
/
/
Fic. 23 a.
a» Py
STREK.
Fie. 23 8.
Uretura Injuries DUE TO SLOUGHING. SLOUGHING OF THE FLOOR OF URETHRA.
(1) Anterior wall of urethra; (2) The site of the posterior wall of urethra which has
sloughed away.
In such cases it is often found possible to reconstruct and repair the remaining parts
of the sphincter in such a way as to ensure moderate control.
) \
|
—
Wy
|
x
\
2 \
i,
i
\\
“fe
/
STREE..
Fic. 23 c.
Urerurar INjuRIEs DUE TO SLOUGHING.
(1) Shows the site of the urethra which has completely sloughed out.
In such cases it may be possible to replace the urethra by constructing a canal lined
with mucous membrane, but efficient sphincteric action is seldom attained.
1
|
}
|
Ureturav Injuries Caused By SLOUGHING.
(1) Partial sloughing of the trigone of the bladder.
In such cases the fistula can be easily closed and efficient sphincteric action attained.
A\ :
(NN INN
j 3
Fic. 23 D.
:
WN
WYN <
SS S OX SN
7 SS SSS
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SSS
Z
WV.
Fic. 23
U L INJURIES I S
(1) Complete des of the trigone of the bladder
In such cases the fistula thou ne ssible _ iy closed, efficie
difficu
| \
/
4
by
WV. STREK.
Fic. 23 F.
ANNULAR SLOUGHING oF Neck oF BLAppeER.
The neck of the bladder has completely sloughed away.
Such cases are exceedingly difficult to cure. In suitable cases, however, anastomosis
between bladder and urethra may be successful, but even then efficient control on urine
may not be attained.
|
\
Fic. 24.
Vesico-URETHRAL ANASTOMOSIS.
First step. The scar tissue has been removed.
=
Fic. 25.
Vesico-URETHRAL ANASTOMOSIS,
Second step. The upper wall of the bladder is dissected out and sutured to the roof
of urethra.
=
=Z7A 1
Fic. 26.
Vesico-URETHRAL ANASTOMOSIS.
Third step. The lower vesical and lower urethral flaps sutured.
|
Fic. 27.
Urinary Fistuta To SLOUGHING oF THE OF THE BLADDER.
The specimen was removed post-mortem from the body of a patient on whom vesico-
urethral anastomosis was performed 7 years previously.
(1) Bladder wall; (2) Pointer in the left ureter. The vesical orifice of this ureter had
been blocked by an old infection with Bilharzia; (3 and 5) Site of the original sloughed
area; (4) A small valvular hole which refused to heal and through which occasional
dribbling of urine occurred; (6) Pointer along urethra; (7) Posterior wall of vagina; (8) Anal
orifice; (9) Pointer in left ureter leading to cavity of bladder; (10) Fundus of uterus;
(11) Tubes and ovaries.
253 Mahfouz’s Obst. & Gyn. Museum.
A
5
6
Fic. 28.
Vesico-CERVICO-VAGINAL FistULA. TRANSPLANTATION OF URETER INTO THE SIGMOID.
(1) Vesico-cervico-vaginal fistula; (2) Bristles passed through the ureteral orifices and in the ureter;
(3) Wall of bladder; (4) Urethra; (5) Body of uterus.
Specimen kindly presented by Dr. N. Makar.
253c Mahfouz’s Obstet. & Gyn. Museum,
4
}
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2
=
3
2
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Fic. 29.
Vesico-CERVICO-VAGINAL FistuLA. TRANSPLANTATION OF URETER.
(1) Ureter; (2) Bristle passed along the transplanted ureter to the colon; (3) Colon. Notice the sloughed
condition of the mucous membrane of the gut below the point of transplantation and compare it with
the healthy condition of the mucous membrane above it (32).
Mahfoyz’s Obstet. & Gyn. Museum,
2—\
3a
2
SOND
or’
Fic. 30.
Vesico-VAGINAL Fisru a.
The specimen represents the genitalia and urinary apparatus of a patient who died of uracmia due to >
chronic pyonephrosis. The vagina is divided from side to side and the flap reflected upwards to expose
the scar of a healed fistula (No. 4) which was operated upon some three months before death.
The urethra (No. 5) had sloughed away as a result of difficult labour.
(1) Anus; (2) Muscles; (3) Portio vaginalis uteri; (4) Scar of the healed fistula; (5) Urethra; (6) Scar
tissue; (7) Labia majora; (8) Ureter; (9) Pyonephritic kidney; (10) Calculus in ureter; (11 and 12) Left and
right tubes matted together in adhesions and lying behind the uterus.
2538 Mahfouz’s Obstet. & Gyn. Muscum. AS Np
AN
JA
8
7
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1
pe)
|
12
;
or
Fic. 31.
Superior Recro-VAGInat Fistuna,
complicated by a vesico-vaginal fistula. The posterior wall of the cervix
implicated in the rectal fistula.
Ny
4
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|
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|
We
ais
ae)
|
RECTO-VAGINAL FISTULA THE RESULT OF AN INCOMPLETE PERINEAL TEAR,
(1) Pointer passed through the fistula to the anus along the rectum; (2) Fistula;
(3) Incompletely healed perineal tear; (4) Anus.
Ss
SS = We A \ \\
| | | || wi \
\ fi)
=
|
“=
Fie. 33.
Traumatic Recro-vaGINAL Fistua.
The rectal mucosa are
The opening into the rectum was the result of rough attempts by the husband to force
an opening into the vagina of a newly married child of 10 years who had vaginal atresia.
This hole was used for coitus during 10 years of married life.
seen prolapsed into the vagina.
|
:
‘
=
v
Fic. 34.
RECTO-VAGINAL FistuL, By Corrus iN Newty Marritp CHILp
10 YEARS OLD
(1) Fundus of uterus (posterior wall): (2) Round ligaments; (3) Hydrosalpinx; (4) Ad-
hesions: (5) Blocked ostium: (6) Part of cervix involved in the fistula; (7) Anterior wall of
vagina; (8) Rent in the rectum.
2
\ —
=
4 —
_
#
Jay
—
Fic. 35.
Superior Recro-vaGINAL FistuLa. First Step.
Incision made in the vault of vagina in order to open the peritoneal cavity
at the pouch of Douglas.
é
\
4
=
‘
ie
>
a
AY,
Fic. 36.
Supertor Recro-vaGINaL Fistuta. Skrconp STep.
Separating the fistula from the surrounding tissues.
‘
f
A
j
4
p
Ws
Fic. 37.
Supertor Recro-vaGINaL Fistuta. Strep.
(1) The scar of a healed vesico-vaginal fistula; (2) Peritoneum closed by interrupted
catgut sutures; (3) The rectal walls of the fistula closed by interrupted catgut sutures.
|
a
y,
Vin
A LE
\
Fic. 38.
Supertor ReEcTo-vAGINAL Fistuta. FourtH STeEp.
The vaginal sutures in position. Silkworm gut sutures are used and the ends are left
long to facilitate removal. In the figure they are cut short for the sake of clearness.
|
——
;
3
The Aetiology of Thrombosis and Embolism
BY
DanIEL DouGaL, M.C., M.D., Ch.B. (Man.), F.C.0.G.*
Professor Obstetrics and Gynaecology, University of Manchester.
THROMBOSIS and embolism are met with as clinical entities in all
three branches of medicine, but to the obstetrician and gynae-
cologist their main importance lies in their relation to the puer-
peral and post-operative states, and it is with these aspects of
the subject that I propose to deal in this report.
During pregnancy, labour or the puerperium, or after a surgi-
cal operation, thrombosis may occur in the veins of the pelvis or
lower limbs.
It may be occult and symptomless, or clinically evident and
associated with fever, pain, tenderness, and oedema of the
affected part.
The disease may end there and recovery then take place after
absorption, organization or canalization of the thrombus, but in
a certain number of cases the whole or part of the clot is detached
and carried through the right heart to the pulmonary arterial bed
where it produces massive embolism or infarction, according to
the size of the vessel obstructed.
These happenings present a problem in aetiology which is
extremely complex, and I think the simplest way to deal with it
is to consider the different factors in the order in which thev
appear in the following classification and then to decide which of
them are most important.
1. Incidence of thrombosis and embolism.
2. Aetiological factors in puerperal and post-operative throm-
bosis.
(a) Primary factors.
(i) Destruction of tissue and its subsequent absorption.
(ii) Sepsis.
* Reporter on the main subject for discussion at the International
Congress of Obstetrics and Gynaecology, Amsterdam, May 1938,
B 425
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
(b) Secondary factors.
(i) Changes in the blood.
(ii) Slowing of the circulation.
(iii) Changes in the vessel wall.
(c) Contributory factors.
Age, sex, body weight.
3. Aetiological factors in pulmonary embolism.
I. THE INCIDENCE OF THROMBOSIS AND EMBOLISM.
Nettelblad’ reports 434 cases of thrombosis and embolism in
50,000 deliveries, or 0.86 per cent, at the South-side Lying-in
Hospital, Stockholm, between the years 1912 and 1927.
Bunzel,’ for the Sloane and Womens’ Hospitals, New York,
gives the incidence of pulmonary embolism in 31,716 parturient
women as 0.I per cent.
Schumacher’s® figures of 6,785 obstetrical and surgical cases
are 0.44 per cent of thrombosis and 0.32 per cent of embolism.
Schmidt,* for the Breslau Women’s Clinic, 1920-1930, reports
0.98 per cent of thrombosis and 0.05 per cent of fatal embolism
in 10,297 obstetrical cases, and 2.19 per cent of thrombosis and
0.42 per cent of fatal embolism following 6,114 gynaecological
operations.
Ducuing’ believes that the incidence of thrombosis and embol-
ism is much higher than the figures given by most authorities
would suggest, and that this is due to minor degrees of these com-
plications being either overlooked or omitted from the statistics.
He himself is careful to include all cases, and consequently his
own statistics give the high incidence of 7.5 per cent of throm-
bosis and ro per cent of embolism for 3,000 surgical operations.
Taking figures from different sources this author has found the
incidence of fatal post-operative embolism to be 0.27 per cent -
161,537 cases.
Wharton® states that nearly half the deaths at the pre
Hopkins Hospital were due to embolism, and analysis of the
reports of most gynaecological hospitals will show that this acci-
dent is by far the most frequent cause of death following
operation.
It is generally believed that thrombosis and embolism have
become more frequent during the last 15 or 20 years. Mayer,’
for instance, reports that at Tubingen the incidence of puerperal
thrombosis has not altered but that of embolism has increased
threefold since 1918, In the gynaecological department of the
426
fl
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
same clinic the incidence of thrombosis has been doubled and
that of embolism trebled during the same period.
At the Burger Hospital and Augusta Hospital, Cologne,
Detering* found that the incidence of thrombosis and embolism
rose from 2.45 per cent of thrombosis and a trifling percentage of
embolism in 1919 to 16 per cent of thrombosis and 3.4 per cent
of embolism between 1924 and 1927.
The increase appears to be both apparent and real, apparent
because more of the slight cases are probably being diagnosed,
real because with the increasing scope and safety of surgery
more poor surgical risks are being submitted to operation.
The incidence of thrombosis and embolism in different
medical, surgical and obstetrical conditions must next be referred
to.
Cardiovascular disease, cancer and debilitated states, and
acute infections are the medical cearitions in which thrombosis
and embolism are most likely to occur.
According to Henderson’ there were 331 cases of fatal embo-
lism at the Mayo Clinic during a period of ro years and of these
about 14 per cent occurred in non-surgical cases.
Abdominal operations are more liable to be followed by
thrombosis and embolism than operations in other parts of the
body.
In his analysis of 267 fatal cases of post-operative embolism
Henderson states that the operation was intra-abdominal in 80.8
per cent and extra-abdominal in 19.3 per cent.
Patey’’ gives figures from 31 of the chief London hospitals
for 1926. Out of a total of 54,253 operations there were 50 cases
of fatal embolism of which no fewer than 43 followed operations
on the abdomen.
Ducuing” gives the incidence of embolism as 14.7 per cent
for abdominal operations, 7.7. per cent for vaginal operations,
and 2.6 per cent for operations on the upper part of the body
and the limbs.
_ Wharton and Pierson’’ report 0.69 per cent of cases of embo-
lism in 1,600 consecutive gynaecological operations.
Schumacher is of opinion that there is not much difference
between abdominal and major vaginal operations as regards
venous thrombosis and that emboli are comparatively frequent,
particularly after vesico-vaginal interposition.
Fatal embolism is undoubtedly much more common after
abdominal operations, but if patients who recover are also in-
cluded the incidence is only about twice as great.
427
\
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Abdominal hysterectomy for uterine fibroids is generally con-
sidered to be the most dangerous operation from the point ot
view of these complications and 75 per cent of all emboli are said
to follow this procedure.
Lister ,’* however, was not able to detect any undue frequency
of thrombosis and embolism in pelvic operations, while in
Petren’s™ series their incidence after operations on the gall bladder
and on uterine fibroids was practically identical.
Thrombosis and embolism may also follow fractures and other
forms of trauma, the incidence of embolism after fracture of the
femur being particularly high.
As already stated Nettelblad found the incidence of puerperal
thrombosis and embolism to be 0.86 per cent. The risk was
definitely greater in cases of difficult labour, particularly after
haemorrhage or manual removal of the placenta.
- According to Bunzel embolism occurs three times as fre-
quently after operative as after normal delivery.
Comment.
Statistics bearing on the incidence of thrombosis and embo-
lism are too variable to be of any real value, but it is evident
that if minor degrees are included, these complications occur
much more frequently than is generally supposed.
There is also a good deal of evidence in support of the view
that their incidence is increasing.
Thrombosis and embolism are most likely to occur after abdo-
minal operations, particularly hysterectomy for fibroids, but
vaginal operations are not immune and carry an incidence of
rather more than 50 per cent of that met with in abdominal cases.
2. AETIOLOGICAL FACTORS IN PUERPERAL AND PosT-OPERATIVE
THROMBOSIS.
(a) Primary Factors.
(i) Destruction of tissue and its subsequent absorption. Dur- ©
ing the puerperium the excess of protein in the uterine wall is
broken down into simpler components and the latter are then
absorbed into the circulation and finally excreted in the urine.
A similar process applies to tissue damaged in the course of
a surgical operation so it is possible to suggest that puerperal
and post-operative thrombosis may be caused by a proteid dis-
integration product which either increases the coagulability of
the blood or damages the vascular endothelium,
428
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
The theory is an attractive one and was supported by Fellner'*
in 1911 and by Lockhart Mummery’® in 1922.
More recently Konig'’ has stated that thrombosis is due to
the liberation of nuclear substances from cells damaged during
the operation, and that their early toxic effects are shown in the
rapid decrease in the number of platelets on the day following
operation and also as a change in the protein factors in the blood.
He points out that thrombosis and embolism are prone to occur
in cases involving much tissue damage such as malignant
tumours, fractures, and inflammatory lesions.
Tannenburg’* believes that morphologically recognizable
necrosis or breakdown of tissue is necessary for the formation
of thrombi. It is well known that the injection of tissue extracts
into the veins of animals may, in certain circumstances, cause
death from intravascular clotting.
Patey’® points out, however, that in these experiments a large
dose of the extract is injected directly into the circulation whereas
it is inconceivable that after any ordinary operation such a dose
could gain entrance to a vessel. He, therefore, carried out some
experiments in which a massive dose of the tissue extract was
introduced into the peritoneal cavity but the results were nega-
tive.
Some observations on the nitrogen content of the blood appear
to have a bearing on tissue breakdown as a cause of thrombosis
and embolism.
A rise in the blood-urea following operation was first observed
by Chevassu*® in 1912 and subsequently confirmed by other
observers. The maximum is reached on the second or third day
and by the fifth day it has usually returned to normal. The
raised blood-urea is not dependent on the severity of the opera-
tion and is probably due to diminished excretion.
The residual nitrogen is partly made up of a number of
substances, notably polypeptides, which occupy an intermediate
position between peptones and amino-acids in the disintegration
of the albuminoid molecule. Normally the blood contains a
certain amount of these substances but following operations there
is a definite rise, as was pointed out by Lambret and Driessens”
in 1930, which reaches its maximum about the fifth day, and is
sharper and more prolonged the more traumatic and histolytic
the operation has been.
The polypeptides are normally dealt with by the liver, so a
persistently high level suggests that the latter is damaged or, at
any rate, is unable to dispose of them.
429
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Pierre Duval, Roux and Goiffon** consider that in a surgical
operation there is a brutal and massive intoxication with. poly-
peptides.
’ As a result of animal experiments and clinical observation
Pierre Duval and Binet®* have come to the conclusion that the
polypeptides play a preponderant part in the production of post-
operative accidents, notably pulmonary complications.
Laporte and Couvelaire** attribute haemorrhagic pancreatitis
and utero-placental apoplexy to similar phenomena.
Meunier,”’ in an extremely comprehensive thesis on humoral
changes following operation, has confirmed these earlier observa-
tions on the polypeptides.
To sum up the nitrogen question, it may be said that the
disturbance following operation consists in a rise of both blood-
urea and polypeptides and that the latter are the more toxic.
Comment.
There can be no doubt that tissue disintegration products play
‘an'important part in the aetiology of thrombosis. Although
‘thrombosis occurs most frequently in puerperal and post-opera-
tive cases it is also met with after fractures, in malignant disease,
and during recovery from acute infections such as typhoid fever
or pneumonia, in all of which absorption of such products is
taking place.
(ii) Sepsis. In every surgical operation there is a possibility
that sepsis has been introduced into the wound or has reached
the operation area from neighbouring organs or structures con-
taining micro-organisms. There is the further possibility that
organisms from a more distant focus may attack tissues the resist-
ance of which has been weakened by the operative procedures.
That frank sepsis is an undoubted cause of intravascular clotting
is proved by the occurrence of pelvic thrombosis in puerperal in-
fection, lateral sinus thrombosis in otitis media and portal vein
thrombosis in appendicitis, to mention only three examples. It
is generally stated, however, that it is unusual to find infection in
the operation field in cases of thrombosis and embolism.
Beckman,” in his review of 6,825 operations, came to the
conclusion that sepsis cannot be the cause of thrombosis. Lock-
hart Mummery strongly supports this view, and points out that
if sepsis were responsible the secondary focus’ caused by an em-
bolus should also become septic. I hardly think that Mummery
is on firm ground here because in every case of pulmonary in-
430
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
farction there is a very considerable febrile disturbance which
may quite possibly be due to infection.
Shaw Dunn,” while agreeing that frankly declared sepsis ot
the surgical wound is not usually present, believes that infection
of some degree can frequently be found, so frequently indeed
that he believes it to be invariable.
De Quervain*®® found that 67 per cent of 267 cases of post-
operative embolism showed infection, and McCartney” dis-
covered 17 wound infections in 31 cases.
According to Schumacher, infection plays an aetiological part
in 60 per cent of cases of post-operative and puerperal throm-
bosis.
Rosenow”’ claims to have isolated a diphatneptoceceus of low
virulence from post-operative thrombi and believes this organism
to be a causative factor.
Glynn” has frequently found a non-haemolytic streptococcus
in cases of pulmonary thrombosis, and is convinced that the
latter is due to mild sepsis. The colon bacillus has also been sus-
pected, but although a likely organism because of its invariable
presence in the pelvic organs, it has never, so far as I know,
been actually demonstrated in an intravascular clot.
Faure® has noticed that thrombosis occurs more frequently
during influenza epidemics, or between December and February
when that disease is apt to be more prevalent.
The relation of sepsis to thrombosis of the lower limbs must
next be considered. In an essay on ‘“The swelling of the lower
extremities incident to lying-in women,’’ published in 1792, Tyre,
of Gloucester,** attributed the condition to lymphatic obstruction
due to inflammation higher up, possibly within the pelvis.
John Hull, of Manchester,** writing on the same subject in
1800, was the first to apply the term ‘‘phlegmasia dolens’’ to the
condition. As one of the predisposing causes he suggested the
overdistended or relaxed state of the blood-vessels of the inferior
part of the trunk or lower extremities produced during the later
months of utero-gestation, but he believed the prominent cause
to be an inflammatory affection located in the muscles and
cellular tissue of the limb and producing a considerable effusion
of serum and coagulating lymph.
Cruveilhier,*® in his article on phlebitis published in 1834,
became the chief exponent of the infection theory of thrombosis.
He regarded the inflammatory changes in the vein as primary
and the clotting of the blood as a secondary phenomenon.
Homans” describes three varieties of thrombophlebitis of the
431
=
be
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
lower extremities, phlegmasia alba dolens or thrombosis of the
deep veins, thrombosis of the superficial veins and thrombosis
of veins which have become varicose. In phlegmasia alba dolens
the frequent swelling of the buttock points to some obstruction
within the pelvis, but a collateral circulation is almost immedi-
ately established, and the white swelling which persists for some
time, or recurs later, is due to lymphatic obstruction.
In superficial thrombosis the great saphenous vein and many
of its branches are permanently damaged, and since the collateral
circulation is inefficient, the limb is congested and the veins tend
to become varicose. The superficial lymphatics, which run in
close relation to the veins, are gradually disabled and take new
courses. As a result of the venous and lymphatic obstruction the
state of the lower leg is bad and gives the impression that the
circulation is seriously damaged. When thrombosis occurs in
varicose veins there is little swelling and induration of the sub-
cutaneous tissues because the lymphatics have previously re-
established themselves in a situation at some distance from the
effected vein.
Brown,”*’ in a clinical study of post-operative phlebitis, states
that the signs and symptoms indicate an infective lesion of the
wall of the vein and that resected segments of superficial veins
show marked inflammatory reaction in all coats and in the
contiguous tissues. Tenderness and fever were present in most
cases, the former in 89 per cent of 87 cases.
Assuming that thrombophlebitis of the lower limbs is due to
infection the latter might reach the vein by the blood-stream or
lymphatics or might produce its effect by inducing changes in the
circulating blood.
Scheidegger™ considers that infection is an important factor in
thrombosis, but believes that it acts by changing the character
of the blood. According to Stohr and Kazda* infection probably
acts directly on the vessel-wall when the thrombosis is close to the
field of operation but on the circulating blood when at some
distance from it. In either case the virulence of the infection
appears to be an important factor, as it has been shown by
Vaquez*’ and others that thrombosis only occurs when the action
of the infecting organism is weak and prolonged. Ducuing is
firmly convinced of the infective nature of many cases of throm-
bosis, but for some years he has been of opinion that there are
other factors which are equally important. When infection is
responsible, however, he believes that it acts by. producing an
endophlebitis.
432
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
Comment.
The evidence that a mild degree of infection is one of the chiet
causes of thrombosis is extremely convincing. The rise of tem-
perature and pulse-rate so frequently met with before the throm-
bosis declares itself, and the more severe pyrexia and ‘constitu-
tional disturbance when the swollen limb or pulmonary infarction
has made its appearance, are difficult to attribute to any other
cause. On the other hand, there are cases of severe, even fatal,
pulmonary embolism which develop within 24 hours of an opera-
tion and before a mild secondary infection is likely to have
developed.
(b) Secondary Factors.
(i) Changes in the blood. The essential feature in the coagula-
tion of shed blood is the formation of insoluble fibrin from soluble
fibrinogen. This is brought about by the action of thrombin
which in turn is produced from an inactive precursor pro-
thrombin by its interaction in the presence of calcium ions with
a disintegration product of blood-platelets and damaged tissue
cells, thrombokinase.
The coagulability of a particular blood may be enhanced by
hereditary, familial or constitutional factors, by pregnancy,
labour and the puerperium, by certain diseases, or by operative
intervention. Little is known about the first two possibilities.
but occasionally one sees cases in which they seem to offer the
most reasonable explanation. As regards general diseases.
thrombosis is liable to occur in the advanced stages of phthisis,
cancer and similar conditions, and during convalescence from
typhoid fever and influenza, but, as in the case of puerperal and
post-operative thrombosis, there are other factors which have to
be taken into account.
In dealing with the blood changes in puerperal and _post-
operative cases it will be convenient to consider first the changes
in the blood-elements and plasma and then to discuss the general
question of increased coagulability. Allen*t examined the blood
of 12 surgical patients, making determinations of the different
factors to be studied within 2 hours before operation, within 4
hours after operation, and on the third, sixth and tenth days.
He found that the leucocytes were consistently increased by about
8,000 cells, the increase being noted soon after the operation.
The number declined sharply between the third and sixth days
and then more gradually between the sixth and tenth days. In
his opinion the increase was mainly due to release of leucocytes
433
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
from temporary storage areas, peripheral vaso-constriction, the
mental status of the patient and tissue trauma, and was of some
significance because the leucocytes are known to be a source of
thromboplastic substances.
According to Wells*? numerous studies on the relation of the
platelets to diseased conditions have indicateda certain parallelism
between their numbers and the tendency to coagulation observed
in the various diseases.
Hittmair,** again, says that it is striking that in cases in which
the platelets are increased by constitutional, post-haemorrhagic,
post-infective, post-operative, or other causes of thrombocytosis,
an increased coagulability of the blood and a tendency to throm-
bosis can be demonstrated. On the other hand, a lengthening of
coagulation time is associated with thrombocytopenia.
Hueck** made blood examinations following 100 operations
and found that the platelet count showed a certain definite
behaviour, namely, a small sinking of the number after opera-
tion, sometimes lasting several days, and then from the seventh
day onwards a strong rise reaching various degrees according to
the severity of the operation and the sensitiveness of the patient.
The increase had usually disappeared by about the tenth or thir-
teenth day.
Dawbarn, Earlam and Howel Evans‘ examined 50 post-
operative cases, 28 cases delivered by the natural passages and
5 cases delivered by Caesarean section, and their findings give
strong support to the hypothesis that the clinical tendency to
thrombosis is correlated with a rise in the platelet count and
increased coagulability of the blood in vitro. A post-operative
rise became manifest about the sixth day, reached its maximum
of about 150 per cent in ten days, persisted for a few days longer
and then returned to normal. Correspondingly the coagulation
time showed a tendency to shorten. These workers also charted
the platelet increase and the day of death in 33 cases of fatal
pulmonary embolism and found that the majority of the deaths
fell within the period of platelet increase. The increase was pro-
portional to the severity of the operation, but they believe that
there is also a constitutional factor in these cases. After parturi-
tion the platelets showed a general tendency to rise and at the
same time there was a slight shortening of the coagulation time.
The rise was much greater after Caesarean section, however, and
more persistent. In both puerperal and post-operative cases the
rise occurred about the same time and corresponded with that of
clinically observed thrombosis.
434
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THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
After examining the possible factors concerned in the platelet
rise the authors concluded that the only one common to all cases
was destruction of tissue and its subsequent absorption. As
regards parturition and operations there appeared to be an
ascending scale reaching its peak in the case of Caesarean section
which, of course, is a combination of both. Apparently they did
not observe the rapid decrease of blood-platelets which Konig
noted on the day following operation and which he claimed to be
one of the early toxic effects of the products of nuclear degenera-
tion in damaged tissues.
Heusser** found the platelets diminished in the first 5 days,
but increased between the eighth and eleventh days. Allen did
not find any uniform variation in the number of platelets.
The different constituents and properties of the blood-plasma
have all been carefully examined in puerperal and post-operative
cases. Gaessler*’ found that in cases of normal convalescence
following operation the fibrinogen was increased, reached its
height on the fourth day, and did not return to normal for 3
weeks. The globulin fraction was also increased but became
normal by the eleventh day. During the normal puerperium
there was also an increase in fibrinogen, highest in the third
week, but a more or less normal globulin content. In cases of
puerperal infection and in 2 cases of fatal pulmonary emboli the
fibrinogen and globulin values were both high.
Gaessler concluded that changes in the albumin factors of the
blood cannot be held responsible for thrombosis and embolism
although they may prepare the way for some other factor to
precipitate the occurrence. Konig believes that both globulin
and fibrinogen are increased after operation. Allen also found a
sharp increase in fibrinogen following operation. This was
marked on the third day and on the tenth day was still uniformly
high and showed no indication of a return to the pre-operative
level. He was of opinion that the increase was probably due to
trauma, producing a demand for an increase in fibrin at the site
of the wound.
With the increase in fibrinogen and globulin the sedimentation
rate might be expected to be increased, but Fahraeus** has noted
that a decrease may have some influence in starting a thrombus.
To investigate the carbohydrate changes Gaessler measured the
blood-sugar, the blood lactic acid and the alkali reserve. In
normal convalescence the blood-sugar and lactic acid rose steeply
in the first few hours after operation and then returned quickly
more or less to normal. The alkali reserve, of course, varied
435
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
inversely with the blood lactic acid. In the puerperium the
blood-sugar and lactic acid, after being high during the second
stage of labour, quickly returned to normal after delivery and
remained normal in uncomplicated cases.
Gaessler quoted a case in which, following operation, the
blood-sugar and lactic acid continued to rise steeply instead of
returning to normal, and the patient had a pulmonary embolism
on the third day. In the infected puerperium the blood-sugar
and lactic acid rise and the alkali reserve falls as the infection
gains ground.
Gaessler sums up the question of plasma changes in throm-
bosis by saying that the optimal condition for the occurrence of
thrombosis and embolism is an increased absolute and relative
fibrinogen and globulin value with a concurrent rise in blood-
sugar and lactic acid, the leading role being played by the carbo-
hydrate change. In this connexion he points out that diabetics
are prone to develop thrombosis.
Meunier’s thesis has already been referred to. He and his
fellow-workers at the hospital of Saint-Germain-en-Laye have
investigated the puerperal and post-operative blood changes with
particular reference to chlorine, nitrogen and sugar. They found
a marked hypochloraemia affecting both the globular and plasma
fractions if the patient had suffered from severe vomiting or pro-
fuse sweating, but otherwise merely a weak hypochloraemia
affecting chiefly the globular fraction and resulting in a notable
reduction of the globular-plasma chlorine ratio. As there was
also a reduction in the amount of chlorides excreted in the urine
the hypochloraemia was evidently due to chloride retention, the
chlorine in the opinion of most of these authorities being fixed
in the tissue or organ injured.
Other changes which they observed and some of which have
already been mentioned are an increased blood-urea and poly-
peptidaemia, hyperglycaemia and a fall of the alkaline reserve.
These workers believe that the changes are due to the brutal libera-
tion of substances from the damaged tissues and they have found
them to be most marked after operations such as hysterectomy
which involve a good deal of trauma. Concentration or dehydra-
tion of the blood, so liable to follow operations, is also recognized
as an important factor in thrombosis and is believed to act by
increasing the aggiutinative powers of the blood.
The general question of increased coagulability of the blood
following labour or operation must next be considered. Allen
found the changes in the coagulation time to be slight and in-
436
Jo |
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
constant.. Keller*® says that the mechanism of post-operative
thrombosis has nothing in common with coagulation of the blood
and cannot be attributed to augmentation following operative
procedures. Vaquez’s opinion is that the chemical and histo-
chemical changes in the blood and the increase in its coagula-
tion, whether due to an excess of fibrin or to an abnormal
number of haematoblasts, are able, though not by themselves, to
play so considerable a preparatory role that one can say of the
blood that coagulation is imminent and that the least contributory
cause will bring it about.
Ducuing thinks that the blood changes may be due in dif-
ferent cases to the condition for which operation has become
necessary, to operative trauma, to diet, or to dehydration, and is
sceptical of the value of coagulation tests carried out im vitro.
Heusser believes that the post-operative changes conduce to an
agglutination of the corpuscles and platelets to each other and to
the vessel-wall and that the enhanced lability of the plasma and
the increase of labile albumin lead to the formation of fibrin and
more ready coagulation.
Scheidegger’s view is that the blood changes are the essential
cause of post-operative thrombosis but that they are the result
of infection.
Dawbarn, Earlam and Evans, while not wishing to lay too
much emphasis on increased coagulability in vitro, think it sig-
nificant that the same tendency to increased coagulability has
been demonstrated by each of them separately in cases following
splenectomy, surgical operation and parturition respectively.
The view they take of these findings is that in the presence of
increased coagulability a clot once started will tend to grow more
rapidly.
Bancroft, Stanley-Brown and Quick®* made a routine study
of the four main elements in blood-clotting, fibrinogen, calcium,
prothrombin and thrombokinase in relation to post-operative
thrombosis and embolism. They consider that fibrinogen plays
a passive role and that its concentration within wide limits has
little influence on clotting time. The same remarks apply to the
blood-calcium as high and low levels have no influence on the
coagulation time, an increase of even 100 per cent being possible
without any intravascular clotting. Their results were based on
certain tests which they devised for estimating the plasma’s clot-
ting time and fibrinogen. |
The normal plasma’s clotting time is 1.45 minutes. Using this
time in seconds as the numerator and the patient’s clotting time
437
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
in-seconds as the denominator these workers obtained an index
which they call the plasma clotting index. Normally this ranges
from 0.8 to 1.05, readings below 0.8 being on the bleeding side,
above 1.05 on the clotting side.
Of 382 patients examined, 31, or 9 per cent, were found to
have a high index, and of these 4, or 10 per cent, had embolism
or thrombosis. As all 4 occurred like an epidemic during the
hot summer months the authors believe that dehydration was
probably an important factor. In patients with high indices and
no obvious peripheral blood-vessel lesions the convalescence was
almost universally abnormal in that there was a longer continu-
ance of fever and progress was not quite satisfactory.
Bancroft and his co-workers conclude that no single factor is
responsible for thrombosis but that the plasma clotting test and
an analysis of fibrinogen will pick out the patient who is sus-
ceptible and who requires energetic prophylactic treatment.
Comment.
There seems to be general agreement that labour or a surgical
operation is followed by definite changes in the composition of
the blood. These changes are extremely complex, but taken as
a whole they only mean that the altered blood may coagulate
more readily in vivo and more quickly in vitro. Some other
factor must be present before intravascular clotting can occur.
(ii) Slowing of the circulation. Virchow” was the great pro-
tagonist of the theory of venous stasis in the aetiology of throm-
bosis. In his view slowing of the blood-stream was the primary
factor and any inflammatory changes in the vessel wall were
secondary and due to the presence of the clot.
Lockhart Mummery believes that a surgical operation predis-
poses to thrombosis by liberating thrombokinase and by produc-
ing venous stasis near the walls of the great veins.
According to Von Jaschke®” slowing of the blood-stream is a
sine qua non of post-operative thrombosis and may act either by
precipitating the formed elements or by increasing the agglutina-
tive power, or even the viscosity of the blood.
Venous stasis may be produced by central or peripheral
causes, an example of the former being a heart embarrassed by
cardiac or pulmonary disease or by the steep Trendelenburg
position and of the latter, interference with the circulation in the
inferior vena cava system by an abdominal operation with its
customary accompaniments and sequelae.
438
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
It-has already been stated that thrombosis and embolism are
much more liable to follow operations on the lower half of the
body. One reason for this is that more complete rest in bed is
usually necessary in these cases but probably a more important
one is the fact that there cannot be any stasis in the superior
vena cava because a free flow of blood to and from the brain is
essential to life. Thrombosis is also more common after abdo-
minal operations and here again there are special factors which
predispose to venous stasis.
During the operation the open wound abolishes the abdominal!
pump mechanism and, therefore, interferes with the circulation
in the inferior vena cava. Swabs packed into the abdomen, par-
ticularly in pelvic operations, may have a similar result. After
the operation the tender wound still interferes with the pump
mechanism and rest in bed in the dorsal or Fowler position may
hinder the return of blood from the pelvis and lower limbs.
_ Venous stasis may or may not involve the veins in the opera-
tion area nor is this necessary for thrombosis or embolism to
occur. Mummery, basing his remarks on a series of fatal cases
of pulmonary embolism from the Mayo Clinic, pointed out that
half the operations were performed on parts of the alimentary
tract which drained into the portal vein and from which a clot
could not possibly reach the lungs.
The effect of stasis on the venous current is well described by
Mummery as follows: ‘‘When fluid is flowing through a channel
or pipe the stream is fastest in the centre of the channel and
slowest at the sides. This can be observed in any river, and is
equally true of the inferior vena cava. If for any reason the
flow is considerably slowed there may be complete stagnation of
the flow against the walls of the channel, although a fair current
is still maintained in the centre. The stagnation will be accen-
tuated at places where side channels come in, as there will be a
tendency to the formation of back eddies at the corners. This is
what I conceive occurs in the inferior vena cava during certain
operations.”’
Evidently Mummery believes that the original thrombus forms
at the time of the operation and spreads during the period of
quiescence immediately following. The fact that thrombosis of
the iliac and femoral veins is more common on the left side (213
out of 232 cases reported by Cordier®) is additional evidence that
interference with the venous circulation is an important factor
because the flow of blood in the left iliac vein is somewhat
hindered by its more oblique union with the inferior vena cava,
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
and by being crossed near its origin by the right common iliac
artery and lower down by the pelvic colon.
Aschoff** assumes a slowing and eddying of the venous circu-
lation, most marked in the veins of the leg, the upper part of the
femoral veins and the pelvic plexus, with a resulting deposit of
blood-platelets near the valves, much as particles floating in a
stream of water of changing velocity may be sifted to the bottom.
Ducuing and others believe that spasm of the vein wall may
be a factor and think that this might be produced by operative
trauma especially in the true pelvis and pre-vertebral region
where large sympathetic plexuses are to be found.
Comment.
The importance of slowing of the circulation is undeniable
and has been amply proved by the reduced incidence of throm-
bosis and embolism among patients whose circulation has been
speeded up by puerperal and post-operative exercises. That stasis
is not a primary factor, however, is shown by John Hunter’s
classical experiment in which he found that clotting did not occur
in a Jength of jugular vein ligatured at both ends and also by
the fact that mere recumbency or lack of movement does not
result in thrombosis apart from operation.
(iii) Changes in the vessel wall, John Hunter’s experiment,
just referred to, proved that intravascular clotting does not take
place in an intact vein. The part of the vein which is of most
importance in this respect is the endothelium and it has even been
suggested that the latter exerts an anti-coagulant action on the
blood. The wall of a vein may be automatically abnormal or it
may be injured by physical or chemical agents, by the action of
micro-organisms, or by disease. Patey has found anatomcial
abnormalities to be extremely rare, but in one of the cases he
investigated a thick valve and a fibrous band attaching it to the
wall of the vein appeared to be responsible for localizing the
thrombotic process and in another there was a septate condition
of the thrombosed iliac vein which may have played a part in the
development of the thrombus.
As long ago as 1784 Charles White,*° of Manchester, suggested
that phlegmasia alba dolens was the result of damage to the
lymphatics by their compression between the foetal head and the
sharp edge of the pelvic brim.
In more recent years Poupart’s ligament, the sitting-up posi-
tion or an undue projection of the sacral promontory have all
440
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
been held responsible, usually on insufficient evidence, for kinking
the femoral or iliac veins and predisposing to thrombosis.
The application of compression forceps or ligatures and the
transfixion of vessels with needles are more convincing examples
of injury by physical methods. In veins which have been liga-
tured and divided, thrombosis is a normal and necessary occur-
rence but should only reach so far as the entrance of the next
tributary vein; if it extends beyond this point there is grave
danger since fragments of the clot may be carried away and
thrombosis result. Mere injury to a vessel, however, is not
followed by thrombosis unless the injury is of a permanent
character, or some other factor is present such as slowing of the
circulation.
Dietrich®* draws a distinction between a localized thrombus
and progressive thrombosis. A localized thrombus has its origin
in reactive changes in the endothelium as a result of increased
absorptive effects, while the building up of a progressive throm-
bosis is concerned with changes in the blood-current such as
waves and swirling.
Ever since the introduction of intravenous medication it has
been known that the injection of an irritant, or of a large
quantity of artificial serum, may be followed by more or less
complete occlusion of the vein.
Ducuing recounts the case of a woman, aged 40 years, with
intraperitoneal haemorrhage resulting from a fall. Before and
after operation for splenectomy she was given 5 litres of serum
and a number of cardiac stimulants intravenously. She died on
the eleventh day, having previously had a severe pulmonary
embolism and hemiplegia, and at the post-mortem examination
she was found to have phlebitis of the left femoral and both
cephalic veins, a pulmonary infarct and an area of cerebral
softening in the internal capsule.
Mechanical and chemical lesions of the vessel wall have been
produced experimentally in animals and therapeutically in the
human subject. Animal experiments have often proved unsatis-
factory, however, probably because the animal gets up and
walks about after the operation or injection.
Homans failed to produce thrombosis in dogs by ligating the
vessel, injecting muscle-extract intravenously or injuring the
intima, but was successful in two cases in which he ligatured the
vessel and at the same time injected some broth culture of
streptococcus viridans into it.
Miller and Rogers” carried out similar experiments in cats
441
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
and in 63 cases were able to produce progressive thrombosis in 1,
small or tiny clots in 14, and a negative result in 48. In the
case in which progressive thrombosis occurred the wound was
septic and there was oedema of the whole limb from periphlebitis
and blocking of the lymphatics.
The injection treatment of varicose veins is an example of the
therapeutic employment of chemical irritants in order to produce
thrombosis, and according to Kilbourne®* has been responsible
for 5 cases of embolism in 53,000 injections, or 0.01 per cent.
Infection has already been considered as a factor in throm-
bosis and all that need be said here is that the vessel may be
injured by direct contact with the infective focus or when the
latter is at a distance indirectly through the lymphatics or blood-
stream.
As regards disease Schumacher has observed that puerperal
or post-operative thrombosis is more liable to occur in varicose
veins but that there is no special predisposition to embolism.
Comment.
Injury to the vascular endothelium is undoubtedly an impor-
tant cause of intravascular clotting and since vessels have to be
clamped and tied in the course of most surgical operations this
factor has also to be considered as a possible cause of post-opera-
tive thrombosis.
There is no evidence, however, that the thrombotic process
actually starts in vessels which have been damaged in this way,
and it is more probable that the endothelium of the thrombosed
vessel is injured either as a result of infection of the wall or of
changes produced in the circulating blood. :
(c) Contributory Factors.
Age. In his analysis of 87 cases of post-operative phlebitis
from the Mayo Clinic Brown found the average age to be 47.1.
years.
In De Quervain’s series of 267 cases of post-operative pul-
monary emboli go per cent were over 40 years of age.
Henderson, in 313 cases of fatal embolism, found that the
average age was 53.2 years and was Io years higher than the
average age of patients coming to operation.
In Ducuing’s experience thrombosis occurs with the maximal
frequency between 50 and 60 years, but he has had one patient,
aged 12 years, on whom he operated for an ovarian cyst, and
442
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
with a colleague has recently reported 5 cases in youths of 20
years of age.
Sex. This factor has no special significance, but the puerperal
cases naturally increase the incidence in the female sex.
In Henderson’s series there were 104 men and IIg women,
and in Brown’ cases 66 per cent were women.
Body-weight. Snell*® examined the question of obesity in
relation to pulmonary embolism and found that this accident was
a more common cause of death in the obese than in the patient
of average weight.
He cannot state definitely whether this is due to the obesity
per se, but there appears to be a group of patients over 50 years
of age, obese and with normal or subnormal blood-pressure, who
are particularly susceptible to pulmonary embolism as a post-
operative complication.
Henderson found the average weight of patients in his series
to be 168 pounds or about 13 pounds overweight.
In Allen’s series of blood examinations there were three obese
patients, and in all of them the fatty acid level was high before
operation, dropped rapidly during the following 6 days and was
still below the pre-operative level on the tenth day. Allen’s com-
ment on this is that its importance is not clear.
Seasonal factors. J. L. Faure believes that there is a seasonal
factor in the development of surgical phlebitis, the condition
occurring most frequently between December and February when
influenza tends to be prevalent. He recalls that during the severe
influenza epidemic of 1919 he had 7 cases of pulmonary embolism
within a month and 4 of them terminated fatally.
Since that time he has noticed a definite rise in the incidence
about January rst and also at other times when there has been a
sudden change in the weather. Ducuing expresses similar views
and appears to think that many cases of thrombosis are both
epidemic and contagious.
Henderson did not notice any seasonal variation, but Brown
found a double peak in the incidence curve of his cases of phle-
bitis, one corresponding to the spring and the other to the fall.
In the case of embolism the curve was different, its peak corres-
ponding with that of the surgical admissions.
Scheidte® is of opinion that weather conditions affect the inci-
dence of thrombosis and embolism and has noticed that emboli
are more liable to occur during cyclones, especially in the warm
sections.
Miscellaneous factors. Almost every conceivable factor has
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
been suggested as a cause of embolism and thrombosis, but the
great majority, if they have any influence at all, are merely con-
tributory and need not be discussed separately.
Comment.
The contributory factors act only by reinforcing the more
important primary and secondary factors and, therefore, further
comment is not necessary.
3. AETIOLOGICAL FACTORS IN PULMONARY EMBOLISM.
Pulmonary complications after a surgical operation may be
due to infection, bronchopneumonia; bronchial obstruction, ate-
lectasis; or vascular obstruction, thrombosis and embolism,
Although pneumonia undoubtedly occurs in elderly and debili-
tated patients, and after ether anaesthesia, it is now recognized
that a great many of the cases formerly diagnosed as such were
in reality minor degrees of embolism and thrombosis.
William Pasteur*’ first described post-operative atelectasis in
1914 and reported 16 cases which had occurred in 2,000 abdo-
minal operations. Since then the condition has become better
understood, and if partial as well as massive cases are included
is now considered to be the condition responsible for 70 per. cent
of post-operative pulmonary complications.
Puerperal and post-operative vascular obstruction are gener-
ally considered to be due to embolism and, therefore, secondary
to thrombosis in some other part of the body. Glynn, however,
takes a different view and believes that most of the sudden deaths
following operation are due to thrombosis. In 35 consecutive
post-mortem examinations, 28 being on post-operative cases, 4
deaths were due to embolism and 30 to primary pulmonary
thrombosis. The diagnosis of pulmonary thrombosis was based
on the presence of antemortem clots, usually in both lungs and
in all lobes, which could not possibly have formed in the short
interval between the acute onset and death, and the recognition
of age changes in the clots as demonstrated by haemolysis and
commencing organization.
As regards the aetiology of primary pulmonary thrombosis
Glynn is of opinion that the main causes are mild sepsis as
revealed by a slight pyrexia and the frequent presence in the
thrombi of a non-haemolytic streptococcus; and pulmonary stasis.
It must be remembered that the pulmonary artery really. be-
haves like a vein and conveys impure blood, so if there are any
444
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
organisms in the systemic blood-stream they are bound to reach
the lungs.
After abdominal operations there is a considerable decrease
in the respiratory function and also a slowing down of the circu-
lation within the chest. Both are due to the abdominal wound
interfering with the range of diaphragmatic movement and with
the pump-like action of the abdominal muscles. Patey demon-
strated these facts by radiological examination of the diaphragm,
by estimating the percentage of carbon dioxide in the alveolar
air and by observing the variations of intra-abdominal pressure
by means of a bag introduced into the rectum.
Churchill and McNeil** found that the expiratory exchange
fell to 25 per cent after operations on the upper abdomen, to 50
per cent after removal of the appendix and to 55 per cent after
operations for hernia. If the peritoneum was not opened the
respiratory exchange was unaffected. A tight abdominal binder
further decreased the capacity by 30 per cent but had no effect
if the patient had not been operated on.
Overholt* visualized the condition radiologically and noted
constant changes in the size and shape of the chest which tended
to decrease the respiratory function.
In the great majority of cases of post-operative and puerperal
embolism the clot is situated in the pulmonary artery, but occa-
sionally it may be in some other vessel.
Wilson collected 47 cases of fatal embolism from the Mayo
Clinic, following 63,573 operations, and of these 36 were pul-
monary, I0 were cerebral, and I was cardiac.
Lockhart Mummery is of opinion that cases of sudden death
without premonitory symptoms must be due to a detached clot
reaching the medulla of the brain as it is difficult to believe that
a normal heart would stop so suddenly from the occlusion of the
pulmonary artery. The primary lesion in such a case might very
well be a pulmonary thrombosis.
Lilian Farrar*' reported 65 embolisms after 30,000 operations
at the Women’s Hospital, New York, and of these 63 were pul-
monary, I was cerebral, and I was mesenteric.
Two varieties of pulmonary embolism are described. In the
first or massive embolism the pulmonary artery, or one of its
main branches, is obstructed and the result is a major surgical
disaster which generally terminates fatally.
In the second variety a smaller vessel is affected and a pul-
monary infarct develops.
The severity of pulmonary infarction varies enormously and
445
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
depends on the amount of lung and pulmonary arterial field
involved. In the normal lung it is difficult to produce infarction
because of the efficient collateral circulation, but Karsner** found
that experimentally introduced emboli would readily cause infarc-
tion after ligature of the pulmonary vein. Infarction will occur
in a normal lung, however, if the embolus occludes a vessel
supplying the edge of a lobe. When the pulmonary circulation
is impaired, as it is so frequently after operation, emboli may pro-
duce infarction no matter where they lodge.
Minor degrees of infarction are extremely common, and, as
already stated, were frequently diagnosed as pneumonia or
pleurisy and attributed to the anaesthetic.
Sudden death after pulmonary embolism is probably due to
shock as a result of the whole or the greater part of the pul-
monary arterial field being cut off or, as Mummery puts it, to
vascular obstruction. between the right and left sides of the heart.
If the patient survives the initial attack she may die in a few
minutes, hours, or days from dyspnoea or dilatation of the right
side of the heart, or she may recover.
Pulmonary embolism is a secondary condition, and a point
of great importance in aetiology is the site of the primary throm-
bosis.
- In Henderson’s series the thrombosis which may have served
as the possible source of emboli was found in 189 of the 313 cases
examined and was situated in the iliac veins in 33 per cent, in
the femoral vein in 29 per cent, in the pelvic veins in 22 per cent,
and in the inferior vena cava in 7 per cent.
Wharton found the original thrombus in the pelvic veins in
16 out of 19 post-mortem examinations on gynaecological patients
who had died of pulmonary embolism.
The type of thrombosis has an important influence on the
severity of the pulmonary lesion, occult thrombosis being more
liable to be followed by serious embolism, and thrombophlebitis
by infarction. This is probably because the inflammatory reaction
fixes the thrombus to the vessel wall and makes it more difficult
for large fragments to become separated.
In 205 cases of thrombophlebitis reported by Wharton there
were 14 cases of infarction, but only 1 case of pulmonary em-
bolism, and in 313 cases of fatal pulmonary embolism analysed
by Henderson only 8.6 per cent had post-operative phlebitis or
symptoms suggestive of that condition.
446
THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
Comment.
Admittedly, conditions in the lungs after operations are ex-
tremely favourable for the occurrence of thrombosis, and it may
be that the majority of deaths from vascular obstruction are
due to this cause. I find it difficult to understand, however, why
a gradual process like thrombosis should give rise to such sudden
and severe symptoms.
As regards embolism there seems to be no doubt that the clot
usually originates in the pelvic, iliac or femoral veins, and that in
the majority of serious cases the thrombosis is of the occult type.
As most of these cases terminate fatally, however, it is quite pos-
sible that the clot became separated at an early stage before
clinical thrombophlebitis had time to develop.
GENERAL DISCUSSION.
The main problem in aetiology is to find out why intravascular
clotting is liable to occur after labour or a surgical operation.
It is quite certain that a single factor is not responsible, and
for my own part I should be prepared to stand by my classi-
fication and say that the two primary causes of thrombosis are
tissue breakdown and sepsis.
I have long held the opinion that a sub-total hysterectomy is
more liable to be followed by thrombosis than a total hysterec-
tomy, and I believe the reason to be that in the latter operation,
at any rate as I perform it, a small opening is left for drainage at
the upper end of the vagina.
If there is no drainage a certain amount of blood or tissue
juice may be retained and serve either as a source of throm-
bokinase or other coagulant, or as a nidus for the growth of low-
grade micro-organisms. I believe the second possibility to be the
more likely one.
The most important secondary factor is venous stasis, and its
presence is usually necessary because thrombosis rarely occurs
if the blood is flowing rapidly.
The blood changes are also important, but only to this extent,
that they make the blood coagulate more readily or more
efficiently. As these changes are fairly constant in puerperal and
post-operative cases, it means that these patients are more sus-
ceptible than others to the dangers of intravascular clotting.
Injury to the vessel wall would be a primary factor if it
could be shown that post-operative thrombosis has its origin in
vessels ligatured, clamped, or otherwise injured in the course of
447
,
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
a surgical operation, but until this has been demonstrated it must
be regarded as a secondary factor linked up with tissue trauma
and sepsis.
The contributory factors do not affect the main problem of
aetiology and, therefore, do not need any further discussion.
CONCLUSIONS.
From a critical examination of the different factors I have,
therefore, reached the following conclusions:
1. Tissue trauma and sepsis are the two primary factors, and
as they frequently co-exist in cases of thrombosis it is difficult
to decide which is the more important.
2. Slowing of the circulation is so important a predisposing
cause of thrombosis that it is almost a sine qua non.
3. Certain changes in the blood occur during the puerperium,
and after surgical operations and cause an increased susceptibility
to thrombosis, but the latter will not occur unless one of the more
important factors is present.
4. There are certain contributory factors, but they merely act
by reinforcing one or other of the factors already mentioned.
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. Bunzel, E. E. Amer. Journ. Obstet. and Gynecol., 1927, xiii, 584.
. Schumacher, P. Arch. f. Gyndkol., 1927, cxxix, 3, 929.
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. Ducuing, J. Le Journ. Méd. Frangais, 1934, xxiii, No. 2, 43.
Wharton, L. R. ‘‘International Clinics,’’ 1936, i, 45th series, 198.
Mayer, A. Munch. Med. Wochenschr.; Brit. Med. Journ., 1931, p. 431.
. Detering. Bruns’ Beitriige zur klinischen Chirurgie, 1928, cxliv, No. 3.
. Henderson, E. F. Arch. of Surgery, 1927, xv, No. 2, 231.
. Patey, D. H. Brit. Journ. Surg., 1930, xvii, No. 67, 487.
. Ducuing, J. ‘‘Phlébites Thromboses et Embolies Post-operatoires,’’
Masson et Cie, editeurs, p. 219.
. Wharton, L. R., and J. W. Pierson. Journ. Amer. Med. Assoc., 1922,
Ixx, 1904.
SOC
N
13. Lister, W. A. Lancet, 1927, i, 111.
14. Petren, G. Beitriige zur klinischen Chirurgie, 1xxxiv, 606.
15. Fellner. Quoted by G. Petren.
16. Mummery, Lockhart. Brit. Med. Journ., 1924, p. 850.
17. Konig, W. Zeitschr. f. Chir., 1933, p. 239.
18. Tannenberg, J. Arch. of Path., 1937, xxiii, 307 and 501.
19. Patey, D. H. Proc. Roy. Soc. Med., 1929, xxii.
20. Chevassu, M. Bull. et Mem. Soc. Nat. Chir., 1930.
N
. Lambret, O., and J. Driessens. C.R. Soc. Biol., 1930, civ, 567.
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THE AETIOLOGY OF THROMBOSIS AND EMBOLISM
. Duval, P.,J.-Ch. Roux, and R. Goiffon. Presse Med., 1934, No. 91,
xlii, 1785.
. Duval, P., and L. Binet. Bull. Med. Acad. Chir., 1936, \xii No. 5, 181.
. Laporte and Couvelaire. Quoted by Meunier.
. Meunier, A. ‘‘Contribution a l'étude des modifications humorales post-
operatoires,’’ Chez Louis Arnette, Paris, 1937.
. Beckman. Quoted by Lockhart Mummery.
. Dunn, J. Shaw. Brit. Med. Journ., 1924, p. 856.
. De Qervain, F. Schweiz Med. Wochenschr., 1925, lv, 497.
. McCartney, J. S., Jnr. Arch. Path. and Lab. Med., 1927, iii, 921.
. Rosenow, E. C. Journ. Infect. Dis., 1927, xl, 389.
. Glynn, E. Brit. Med. Journ., 1924, p. 323.
. Faure, J. L. Soc. de Chir. Bull. et Memoirs, Paris, 1927.
. Tyre. ‘‘An Essay on the Swelling of the Lower Extremities wemmneaes to
Lying-in Women, 1792.”" Quoted by John Hull.
. Hull, John. ‘‘An Essay on Phlegmasis Dolens, including an account
of the symptoms, causes, and cure of peritonitis puerperalis and con-
junctiva.’’ Manchester, 1800.
. Cruveilhier. Art. Phlébite (Dict. de,Med. et de Chir. Pratiques), 1834,
Pp. 637.
. Homans, J. Ann. Surg., 1928, Ixxxvii, 641.
. Brown, G. E. Arch. of Surg., 1927, xv, 245.
. Scheidegger, W. Schweiz Med. Wochenschr., 1928, No. 4, p. 78.
. Stohr and Kazda. Deutsch. Zeitschr. f. Chir., 1928, ccviii, 104.
. Vaquez et Mayet. Congrés Francais de Medicine, Nancy, 1896, pp. 228,
267.
. Allen, E. V. Arch. of Surg., 1927, xv, 254.
. Wells, H. G. Chemical Pathology, 5th ed., London and Philadelphia,
1926.
. Hittmair, A. Folia Haematol., 1927, xxxv, 156.
. Hueck, H. Munch. Med. Wochenschr., 1926, \xxiii, 173.
. Dawbarn, R. Y., F. Earlam, and W. Howel Evans. Journ. Path.
and Bacteriol., 1928, xxxi, 833.
. Heusser, H. Schweizerische Med. Wochenschr., 1925, lv, 520.
. Gaessler. Arch. f. Gyniik., 1932, cxlix, 650.
. Fahraeus. Physiol. Rev., 1929, ix, 241.
. Keller. Arch. f. Gynakol., 1912, xcvii, 540.
. Bancroft, F. W., M. Stanley-Brown, and A. J. Quick. Amer. Journ.
of Surg., 1935, N.S. 28, p. 648.
. Virchow, R. Arch. f. Path., Berlin, 1856.
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. Cordier. Journ. Amer. Med. Assoc., 1905, |xv 1792.
. Aschoff, L. Lectures on Pathology, New York, Paul B. Hoeber, 1924,
Pp. 253-
. White, Charles. ‘‘Inquiry into the nature and cure of that swelling in
one or both of the lower extremities which sometimes happens to lying-
in women.’ 1784.
. Dietrich, A. ‘‘Thrombose ihre Grundlagen und ihre Bedeutung.”’
Berlin: Julius Springer, 1932.
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34 |
35 |
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37
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43
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45
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53
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57- Miller, R. H., and H. Rogers. Journ. Amer. Med. Assoc., 1929, xciii,
No. 19.
58. Kilbourne, N. J. Journ. Amer. Med. Assoc., 1929, xcii, 1320.
59. Snell, A. M. Arch. of Surg., 1927, xv, No. 2, p. 237.
60. Scheidte, F. Deutch. Zeitsch. f. Chirurg., 1933, 239.
61. Pasteur, W. Brit. Journ. Surg., 1914, i, 587.
62. Churchill, E. D., and D. McNeil. Surg. Gynaecol. and Obstet., 1927,
xliv, 483.
63. Overholt, R. Journ. Amer. Med. Assoc., 1930, xcv, 1484.
64. Farrar, Lilian K. P. Surgical Clinics of North America, April 1935,
xv, No. 2.
65. Karsner, H. T. ‘‘Human Pathology,’’ 1926.
450
*
Post-Operative Exercises as a Preventative of Embolism
BY
WILLIAM FLETCHER SHAW,
M.D., Ch.B. (Manch.), F.C.0.G., Hon. F.A.C.S.,
Professor of Clinical Obstetrics and Gynaecology, Manchester
University; Hon. Gynaecological Surgeon, Manchester Royal
Infirmary ; Honorary Surgeon for Women, St. Mary’s Hospital,
Manchester,
AND
C. E. B. Rickarps, M.B., Ch.B. (Manch.), M.C.O.G.,
Chief Assistant Gynaecological Unit, Manchester Royal
Infirmary.
PooLe,' in 1913, advocated the routine use of post-operative
systematic exercises, a suggestion which was followed by other
operators.
A short time after the Great War one of us (W. F. S.) was
much impressed by a statement by Blair-Bell in a discussion in
the North of England Obstetrical and Gynaecological Society.
We cannot find any record of this discussion, but in it Blair-Bell
stated that he had been so much impressed by Poole’s work that
he had instituted these exercises in his gynaecological wards in
the Liverpool Royal Infirmary.
It is generally accepted that pulmonary embolism is more
prone to occur after pelvic operations than after operations in
other parts of the body and yet, in this discussion, Blair-Bell
was able to show that, during a trial of some years’ duration, the
incidence in his gynaecological wards was much iess than in the
general surgical wards.
So impressive were the figures that the sister of the gynaeco-
logical ward of the Manchester Royal Infirmary was asked to
institute these same exercises in her ward and, since that date,
15 or 16 years ago, she has meticulously carried them out.
Three times daily, while the ward is closed for toilet attention,
exercises are carried out—generally to a tune sung by the patients
* Read at the November (1937) meeting of the North of England
Obstetrical and Gynaecological Society.
451
7
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
themselves. The convalescent patients lift their arms high over
their heads twenty times and then, lying on their backs, lift each
leg the same number of times. Naturally, during the first few
days after an operation the patients cannot elevate their limbs
so often but, even a day after an operation, the patient can lift
her arms a few times while her legs can be drawn up to her body
and then fully extended. This necessitates the removal of the
pillow which normally supports her legs, and this is probably
one of the greatest benefits, as the constant clinging pressure on
the back of the thighs must retard the venous circulation.
At its worst fatal pulmonary embolism is a rare disaster, and
no one noticed that these distressing cases occurred much less
frequently in the Royal Infirmary than in the adjacent St. Mary’s
Hospital. In fact, as the exercises took place only when the
ward was closed and, therefore, were not seen by the surgical
- staff, most of us forgot that they were still taking place. But
Sister James, without any encouragement or further instruction,
persevered and three times daily each patient has had her exer-
cises during these 15 years.
After a fatal case of pulmonary embolism at St. Mary’s Hos-
pital—when every possible cause was under review—one of us
noted the fact that these exercises were still systematically carried
out at the Royal Infirmary and suggested that an inquiry should
be made over a number of years.
The circumstances were particularly fitting for such an experi-
ment as the gynaecological ward at the Royal Infirmary and one
of the units in the adjacent St. Mary’s Hospital were under the
care of one gynaecologist (W. F. S.), and it was decided to
investigate every case operated upon by that gynaecologist in
each of these institutions during the past 12 years.
The surgeon, theatre-management, and after-care of the
patients were as nearly as possible the same in each institution
with the exception that graduated exercises were given in one
institution and not in the other.
One other difference was in the anaesthetics. In the Man-
chester Royal Infirmary avertin has been largely used for the last
g years while at St. Mary’s Hospital it has only recently been
employed, and even now is not used nearly so frequently as in
the other institution. We are doubtful, however, if this is a
factor as there does not seem to be any difference in the incidence
during the years when the basal narcotics were most used.
All these operations were performed by one of us (W. F. S.),
and none have been included which were done by another sur-
452
POST-OPERATIVE EXERCISES AS A PREVENTATIVE OF EMBOLISM
geon or assistant. The investigation has been made by the other
(C. E. B. R.) and the results have been very interesting and
even startling.
At the Manchester Royal Infirmary—where regular exercises
were given during the post-operative period—the gynaecologist
operated upon 1,635 cases in the last 12 years. One case of fatal
pulmonary embolism occurred among this series and that was in a
patient with a bad operative risk and known to be suffering from
pulmonary tuberculosis. This gives a percentage incidence of
fatal pulmonary embolism of 0.06.
In St. Mary’s Hospital—where exercises have not been per-
formed—the same gynaecologist operated upon 3,618 patients in
the same period. Of these 11 died in the post-operative period
from pulmonary embolism: a percentage incidence of pulmonary
embolism of 0.304.
TasLe I.
Number
of fatal
Number cases of
of pulmonary Per-
Institution Exercises patients embolism centage
Royal Infirmary 635 I 0.06
aay’ s Hospital ... Not given 3,616 II oO.
Expressed in percentages the seicidienes was ied times as great
in the hospital in which regular exercises were not given as in the
one in which regular systematic graduated exercises were insisted
upon.
The fatal cases from pulmonary embolism at St. Mary’s
Hospital were :
Taste II.
. Insertion of radium for stage iii carcinoma of the cervix.
. Anterior colporrhaphy and colpo-perineorrhaphy, and amputation of the
cervix.
. Chronic metritis and ovarian dermoid cyst treated by panhysterectomy
and the removal of the dermoid tumour.
. Supravaginal hysterectomy and removal of the ovaries in a case of fibroids
associated with bilateral endometriomatous ovarian cysts.
. Supravaginal hysterectomy and removal of both appendages in a patient
with bilateral ovarian tumours.
. Excision of the vulva and block dissection of the glands of the groin in a
case of epithelioma of the vulva
. Myomectomy.
. Left ovariotomy.
453
I
2
3
4 :
6
7
8
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
g. Ventral fixation and removal of the appendix.
to. Ovarian cyst, malignant, treated by removal and panhysterectomy.
11. Supravaginal hysterectomy and removal of the ovaries in a case of fibroids
associated with bilateral endometriomatous ovarian cysts.
The above do not point to any pathological lesion or opera-
tion as being especially liable to be followed by pulmonary
embolism.
In this paper we have included only fatal cases of pulmonary
embolism. During these 12 years there must have been many
patients with small emboli who recovered, especially patients
with so-called pleurisy which we consider to be due to small
emboli. It would have been interesting to give these, but the
post-operative notes were often so imperfect that it was impossible
to collect figures which would be reasonably accurate. More-
over, the case which appals the surgeon is the fatal one—usually a
complete bolt from the blue in a patient who apparently is mak-
ing an uninterrupted recovery—and so we have confined our
investigation to the fatal cases.
The figures were submitted to W. L. Stevens of the Galton
Laboratory, University College, London, to be analysed statisti-
cally. He wrote that: ‘‘Although the results do not justify the
conclusion that the lower incidence of pulmonary embolism in
the exercised group was due to exercise, they are sufficiently
suggestive of this possibility to warrant the collection of further
data.’’
Although a pure statistician cannot accept these figures as
being entirely free from risk of error, to the clinician—who must
necessarily be limited to what a statistician considers small figures
—they are very suggestive. Here are two fairly large groups of
patients operated upon by the same man and, except in one par-
ticular, treated in the same way. In one group the incidence of
pulmonary embolism is five times greater than in the other group.
Moreover, these fatal cases are scattered fairly regularly over the
12 years and not congregated into one period when some tem-
porary accidental factor might have been present.
As clinicians we feel that this factor, post-operative exercises,
is probably the reason for the lowered incidence in the group in
which they were regularly practised and we have now instituted
them in all our wards.
SUMMARY.
In two institutions, in wards under the care of the same
gynaecologist, admitting the same type of patient, with the same
454
POST-OPERATIVE EXERCISES AS A PREVENTATIVE OF EMBOLISM
pre-operative and post-operative treatment—except that in one
systematic graduated post-operative exercises were given and not
in the other—this gynaecologist performed 1,635 consecutive
operations in the hospital with graduated exercises with an inci-
dence of fatal pulmonary embolism of 0.06 per cent.
In the other hospital, without graduated exercises, the same
gynaecologist in the same years performed 3,618 operations with
an incidence of fatal pulmonary embolism of 0.304 per cent, a
percentage incidence five times as great as in the other group.
REFERENCE,
1. Poole, E. ‘‘Systematic exercises in post-operative treatment.’’ Journ.
Amer. Med. Assoc., 1913, 1x, 1202. as
455
Post-partum Necrosis of the Anterior Pituitary ;
Pathological and Clinical Aspects
BY
H. L. SHEEHAN, M.D., M.Sc. (Manchester) and Rosin MuRDOcH,
M.B., Ch.B. (Glasgow).
From the Research Department, Glasgow Royal Maternity
and Women’s Hospital.
In a recent article (Sheehan') it was shown, both from cases
personally examined and from a review of the relevant literature,
that (a) extensive ischaemic necrosis of the anterior pituitary is
a not uncommon incidental finding at autopsy in women who die
during the puerperium. The necrosis appears to be caused by
collapse of the patient at delivery, due in the majority of cases
to severe haemorrhage, but it cannot usually be recognized
histologically until 14 hours or more post partum. (b) In patients
who die of Simmonds’s disease which originated from a delivery
a long time previously, the pathological appearances of the
anterior pituitary correspond to the healed stage of this necrosis.
Where a history of the delivery is available it appears that the
delivery was always a amend by collapse, usually due to
haemorrhage.
Pathology.
To illustrate the early stage, two new cases are described in
which recent post-partum necrosis of the anterior pituitary was
found at autopsy.
Case 1. Extensive necrosis due to haemorrhage and collapse
at delivery. The caseis complicated by a pre-existent myxoedema.
Aged 40 years, 8-para. A rather fat woman with scanty eye-
brows and head hair, and a myxoedematous appearance of the
face. Her last two pregnancies ended in abortion at 4 months;
the other five were full-time spontaneous deliveries.
She was admitted at term after 36 hours in labour, dispropor-
tion due to the large size of the foetus being the cause of the
delay. Two hours later a rupture occurred in the lower uterine
segment with severe haemorrhage into the peritoneal cavity; the
patient became desperately collapsed’, quite unconscious, and
456
Fic. 1.
Necrosis of the entire anterior lobe of the pituitary.
Fic. 2.
Necrosis of about two-thirds of the anterior lobe of the pituitary.
(Horizontal sections, x5. The dark areas are live anterior lobe tissue;
the pale areas are necrosed. The posterior lobe is seen at the bottom of
the sections.)
y
-
ye
‘
—S
Ny
‘Cc vay
‘
POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
moribund. Laparotomy and hysterectomy were performed at
once, an anaesthetic not being required as the patient was
so deeply unconscious, and two blood transfusions were given.
Though the immediate prognosis appeared quite hopeless,
the patient recovered from the operation. During the next three
days she was placid and cheerful, but abdominal distension and
vomiting then developed; the temperature varied between g9 and
100°F., and the pulse-rate between 120 and 135. At 6 days post-
partum she suddenly became drowsy and died a few hours later.
At autopsy there was a localized pelvic peritonitis with a
recent spread to the general peritoneum, and terminal hypostatic
pneumonia. The anterior pituitary showed gross necrosis and,
in addition, was rather larger than are most pituitaries 6 days
after delivery. The thyroid gland was represented only by a
small white mass of fibrous tissue, in which microscopic examina-
tion reveals scattered small islets of atrophic alveoli surrounded
by accumulations of lymphocytes.
Histologically the anterior pituitary is almost completely
necrosed; the only live parenchyma which remains is in two
small areas under the capsule in front, and a narrow band along
the edge in contact with the posterior lobe. The general ap-
pearances are shown in Fig. 1, though the areas of live tissue
are too small to be recognizable in this section. Most of the
necrosis appears to be several days old, and shows complete loss
of nuclear staining in parenchyma and interstitial tissue; there is
the usual retention of staining power by the granules in the acido-
phile cells. There are two ill-defined areas of less advanced
necrosis near the centre of each half of the anterior pituitary just
in front of the main arteries. In these areas the tissue appears
somewhat oedematous and there is still a very faint haemalum
staining of nuclear ghosts. Near the surface of the necrosis the
capillary endothelium is intact and rather swollen though the
parenchyma here shows advanced necrosis. There are no poly-
morphs in this region but more deeply, about 1 mm. beneath the
surface of the necrosis, there is a band of degenerate polymorphs.
Where the necrosed area abuts on live tissue the margin is quite
sharp with no trace of any atrophy of the live acini and no accu-
mulation of any lymphocytes or plasma cells. Four small sinuses
near the surface of the necrosis on the left side contain fibrin
thrombi which appear to be a few days old. The main arterv
in the left half of the gland shows extensive infiltration of its
media by fibrin, but the artery is not thrombosed.
Remarks. This history of severe haemorrhage and collapse
457
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
at delivery is very typical; with such extreme collapse the chances
that the pituitary will escape necrosis are very slight. Greater
interest lies in the finding of a fresh pituitary necrosis in a patient
with an old standing fibrosis of the thyroid gland. As the patient
did not survive, the effect of subsequent absence of thyrotropic
hormone on a thyroid with pre-existent fibrous atrophy remains
a matter of speculation. But if she had recovered from the
delivery there are obvious possibilities of a subsequent clinicai
or pathological misinterpretation of the case. This raises the
question whether there may be multiple aetiological factors in
certain cases of pluriglandular sclerosis (see Sourdel,* Falta,* and
Boller and Goedel*). It may be noted here that clear evidence
has not been found in the literature to indicate that hypothyroid
patients have a particular tendency to haemorrhage or collapse at
delivery.
The chief points of histological interest in the pituitary are the
arterial Jesion and the fact that at 6 days post partum no early
stages of a zone of secondary atrophy can yet be found. The
apparent age of the more advanced parts of the necrosis is in
agreement with the view that the lesion began at about the time
of delivery; the more recent parts of the necrosis may date from
perhaps two days later.
CASE 2. Large necrosis due to post-partum collapse which
was partially obscured by eclamptic coma. Aged 28 years, 2-
para. At 32 weeks gestation the patient developed a hypertensive
toxaemia which did not respond to treatment and developed into
eclampsia at 37 weeks. She had a spontaneous delivery during
the eclampsia; there were 7 fits in the 18 hours ante partum and
5 fits in the 4 hours post partum. During the period from 4 to
18 hours post partum she remained comatose with temperature
of 100 to r01°F., but the pulse suddenly became very weak and
rapid (about 150) and repeated injections of cardiac stimulants
were required. After this she improved gradually for 2 days
but then developed signs of broncho-pneumonia and died 3} days
post partum.
At autopsy the typical lesions of eclampsia were found in the
liver and kidneys and there was gross broncho-pneumonia in
both lungs. The uterus showed some intramuscular and sub-
peritoneal haemorrhages. The anterior pituitary showed a large
necrosis.
Histologically the pituitary necrosis has a very patchy distri-
bution, as is seen in Fig. 2. Much of it does not show any nuclear
staining but there are some areas of less advanced necrosis, par-
458
POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
ticularly near the front in the mid-line where the lesion appears
to be of only about 14 days’ duration. The older parts of the
necrosis have a slight even infiltration with polymorphs for a
depth of about 1 mm. from the surface; the capillary endo-
thelium near the surface remains healthy but is not so swollen as
in the previous case. The areas of live parenchyma appear quite
healthy. Several sinuses in various parts of the anterior jobe
contain fibrin thrombi which appear to be 2 or 3 days old.
Remarks. The chief interest in this case concerns the condi-
tion at delivery. There was only slight blood loss, and the
aetiological factor thus appears to have been purely post-partum
collapse on a basis of eclampsia and slight accidental haemor-
rhage. The collapse occurred during the eclamptic coma and
would have been hidden by it if the poor condition of the pulse
had not been noticed.
Histologically there are no unusual features; the more ad-
vanced parts of the necrosis appear to be almost 3 days old.
AETIOLOGY OF THE NECROSIS.
The frequency with which the necrosis is found at autopsy
and the actual size of the lesion bear a clear relation to the
severity of the haemorrhage collapse at delivery. Table I shows
I.
Relation of frequency of occurrence and size of necrosis at autopsy to grade
of haemorrhage collapse at delivery 14 hours to 30 days before death.
Grade of haemorrhage collapse
Size of necrosis
Complete or almost complete 4
I
I
Medium
Small
None present
3 2
(The figures indicate the number of patients.)
the findings in a consecutive series of 46 full autopsies on patients
dying later than 14 hours post partum. The severity of the
haemorrhage collapse is graded numerically according to the
method described below in the section dealing with the first
follow-up. Grade 5 is the most severe. As it is not always
possible to assess very trivial degrees of haemorrhage collapse, a
few patients placed in grade 0 may really belong to grade 1: in
14 of these grade 0 cases there had been operative delivery,
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
anaesthesia, or eclampsia, but in none of them was any unusual
bleeding or any collapse noted in the records. This point, how-
ever, hardly affects the significance of the Table.
Pituitary necroses were not found in 18 women dying before
delivery nor in 24 women dying during the first 14 hours after
delivery. Of these latter 24 patients, 6 had severe and 13 had
fatal haemorrhage collapse, but death occurred too soon for any
incipient necroses to become recognizable histologically.
It is of interest that the necrosis is found after haemorrhage
collapse at delivery but not after haemorrhage collapse in the
absence of pregnancy. For instance, there were not any cases re-
ported in soldiers during the war. The association with delivery
is to be related to the sudden change from the marked hyper-
trophy of the anterior pituitary during pregnancy to the rapid
involution during the puerperium. At a normal delivery there
is presumably a physiological reduction of the blood-flow to the
anterior lobe; if in addition to this there is a severe general circu-
latory collapse, it is possible that the blood-flow to the anterior
lobe may be so reduced that thrombosis occurs in the vessels
of the lobe and leads to the ischaemic necrosis. This explanation
is obviously quite speculative.
Table II shows that there is no recognizable relation be-
tween the occurrence of pituitary necrosis and the finding of
sepsis or inflammation anywhere in the body at post-mortem.
It is commonly accepted that post-partum necrosis of the anterior
pituitary is due to embolism as a result of puerperal sepsis. The
present findings are in disagreement with that view.
Taste II.
Pathological findings in 46 women dying later than 14 hours post partum.
Showing the lack of relation between pituitary necrosis
and sepsis or inflammation.
Total Number
number of with pituitary
cases necrosis
All autopsies 46 13
No sepsis or inflammation whatever II 3
Other sepsis or inflammation (pye-
litis, endocarditis, venous throm-
bosis, abscesses, etc.) ... 24 5
460
POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
Clinical Aspects.
The conclusion that the pituitary necrosis is due to haemor-
rhage and collapse at delivery is based so far only on cases
examined post-mortem; it should, however, be capable of con-
firmation by the clinical examination of patients who survive.
Two lines of approach to this problem are available:
(a) To look for evidence of hypopituitarism in patients who
have survived haemorrhage and/or collapse at delivery.
(b) To find whether there is a history of haemorrhage and/or
collapse at delivery in patients who have evidence of hypo-
pituitarism.
First Follow-up. Clinical Investigation of Patients some Years
after a Delivery with Haemorrhage or Collapse.
For this study it was necessary to collect a group of patients
who had had marked haemorrhage or collapse at delivery but
had recovered, and about whom complete details of the delivery
and puerperium were available. For this purpose the records
of all such cases in the hospital during the years 1930 to 1936
were examined and, from these records, the grade of severity of
each case was assessed according to the total number of marks
which were given for haemorrhage and for collapse. These
marks were allocated for each condition separately as shown in
the following schedule.
Haemorrhage. One mark, severe haemorrhage; two marks,
very severe haemorrhage, mucosae pale, patient restless and defi-
nitely requiring transfusion; three marks, extreme haemorrhage,
sighing respirations, air hunger, patient exsanguinated and re-
quiring immediate intravenous saline until a blood transfusion
can be given.
Collapse. One mark, collapse, pulse-rate less than 140; two
marks, severe collapse, pulse-rate over 140, patient may or may
not be in obvious coma but remembers nothing afterwards;
three marks, extreme collapse, pulse imperceptible, patient coma-
tose, condition ‘‘grave’’ or ‘‘moribund’’.
This assessment from the two aspects gave a reasonably true
estimate of the patient’s general condition at or just after delivery,
though cases of pure collapse without haemorrhage were perhaps
assigned to a somewhat low grade.
The cases fell thus into 6 grades; the highest grade with 6
marks was very small and was incorporated with the rather
larger grade 5. A follow-up was then undertaken of all patients
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in grades 3, 4, and 5, of a large proportion of those in grades I
and 2, and of a control series (grade 0) of multiparae who had
not had any haemorrhage or collapse in their last delivery. Less
than half the patients could be traced and examined, but there is
not any reason to doubt that they are representative of the whole
group. A routine clinical investigation of all these patients was
made and, where any indications were present, careful physical
examination and chemical studies were performed. In all, the
actual follow-up consisted of 128 women who had had haemor-
rhage collapse at delivery and 64 women whose previous delivery
had been normal.
GENERAL SYMPTOMATOLOGY.
It is sufficient in this connexion to discuss only the clinica!
findings. These appear to have enough significance in themselves
to be used as a basis for diagnosis, even without the support of
the biochemical findings which will be reported in another paper.
Apart from the question of lactation, the only symptoms to be
considered here are those which date from, and have continued
since, the significant delivery. No notice is taken of temporary
symptoms during the 3 months following delivery when the
patient was convalescing from the complicated labour and blood
loss, nor of symptoms which date from before the delivery, nor
of symptoms due primarily to obvious conditions such as anaemia,
under-nutrition, neurosis or heart disease.
III.
Relation of individual symptoms to severity of haemorrhage collapse at
delivery.
Grade of haemorrhage collapse
4 3 2 I o
Total
cases 20: 30. $f 26...
Absence of mammary reaction 44 9. 33 31 8 3 —
Menses absent or infrequent ... 32 Dr. 22 5 4 —- —
Cold syndrome ......_... 25 5 12 6 2— —
Loss of body hair... ... II 3 4 2 2— —
Adiposity se 21 2 4 5 3 —
(The figures in each column indicate the number of patients in that grade
who show the particular symptom.)
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
The significant symptoms require a short description before
the condition of the individual patient is summarized; the symp-
toms are absence of mammary reaction, absence or infrequency
of menses, ‘‘cold syndrome’’, loss of body hair, and adiposity.
The relation of these symptoms to the grade of haemorrhage
collapse is shown in Table III.
Absence of Mammary Reaction.
This refers to the puerperium of the delivery in question. In
these patients the breasts involuted at once after the delivery
without any general or local treatment; there were not any signs
of commencing lactation, not even slight swelling or discomfort,
such as are normally present about the fourth day of the puer-
perium. .Among the patients showing this symptom suckling
was usually not attempted, as many were considered unfit or had
had stillbirths, but this factor in itself does not inhibit the norma!
mammary reaction.
This symptom shows a frequency in direct proportion to the
grade of haemorrhage collapse, and is presumably due to lack ot
secretion of the lactogenic hormone by the anterior pituitary.
As it can only occur in the early puerperium it is an indication
of pituitary insufficiency at that time only. Such insufficiency
may be merely a temporary expression of the severe disturbance
of the body in general due to the haemorrhage collapse which
had just occurred in the patients studied. Nevertheless, in certain
cases the symptom appears to be the first evidence of a perma-
nent pituitary insufficiency.
Menses Absent or Infrequent.
This refers to a gross reduction or complete cessation ot
menstruation continuing for a long period or permanently after
the delivery and sometimes associated with genital atrophy.
Those cases are not included in which any general complicating
factors can be found, such as irregularity of menstruation before
the pregnancy or suckling the baby after the delivery, or where
the menstrual disturbance could be related to the ordinary meno-
pause or to any pelvic condition.
The patients classified as normal under this heading had
menses beginning at I to 3 months post partum or, when the
child was suckled, towards the end of lactation; the menstrua-
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
tion continued afterwards as usual except in two women who had
some menorrhagia due to subinvolution.
The frequency of occurrence of partial or complete amenor-
thoea shows a definite relation to the grade of haemorrhage
collapse. The cases are discussed in more detail below; here it is
sufficient to remark that the symptom is considered as a probable
indication of a continuous under-production of gonadotropic
hormone by the anterior pituitary. This is, of course, particularly
the case when there is genital atrophy due to complete absence of
oestrin activity.
Cold Syndrome.
This term is used here only as a conveniently short designation
for a symptom-complex which dates from the delivery. The
syndrome consists of: (1) Hypersensitivity to cold. The patient
is unable to keep warm and sits close to the fire for most of the
day. She wears extra clothing and has a marked dread of the
winter. (2) Asthenia, shown by inability to do ordinary house-
work. (3) Apathy. The patient loses her spontaneous interests
and can only be persuaded with difficulty to visit friends and
entertainments. According to her relatives, ‘‘she just sits’’. She
is suspicious of any form of medical examination. The voice
becomes slow and monotonous. Libido is sometimes _iost.
(4) The weight may remain the same or may decrease by 15 to 25
pounds; marked emaciation is rare. In this connexion it should
be explained that minor loss or gain of weight (less than 15
pounds, and not necessitating readjustment of clothing) is passed
as normal.
This description is of a well-marked case, but the syndrome
may be of varying degrees of severity. In milder cases certain
of the symptoms may be slight or even absent (this applies
particularly to the mental symptoms) and the condition could be
classed as only an extreme ‘general debility’. The more severe
cases may have many of the appearances of myxoedema, or may
give a clinical picture similar to that seen in fully developed
Simmonds’s disease.
The frequency of occurrence of the syndrome shows an
obvious relation to the grade of haemorrhage collapse. In view
of its sudden onset after the delivery and its association with other
symptoms it may be regarded in these cases as a result of
insufficient production of thyrotropic hormone, and possibly also
of adrenotropic hormone, by the anterior pituitary.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Loss of Body Hair.
A few of the patients show this symptom. Complete loss of
pubic hair is rare, particularly in the region of the labia, but loss
of axillary hair is more common. Only marked alterations from
the previous condition are recorded. Temporary thinning of head
hair is a common occurrence after delivery, and will not be
considered here.
Loss of body hair is closely related to the grade of haemor-
rhage collapse at the delivery and is probably an indication that
the anterior pituitary is producing insufficient adrenotropic or
gonadotropic hormone.
Adiposity.
Some women have a sudden increase in weight after a
delivery, from 20 pounds to 40 or even 50 pounds. They develop
the opposite of the ‘cold syndrome’ in that they enjoy cold
weather, they are able to do their housework easily and are
mentally bright, cheerful and co-operative. Only if the weight
increase is very marked does the patient tend to feel rather lazy.
This symptom is not uncommon after any sort of delivery. It
is no more frequent after haemorrhage or collapse than after
normal deliveries, and does not appear to be due to any pituitary
insufficiency. A satisfactory explanation for it cannot be offered
here; in particular it does not show any significant relation to
puerperal sepsis in the series under review. Its chief importance in
the present connexion is that it may occur incidentally in women
who also have symptoms suggesting pituitary insufficiency. When
this happens it nearly always completely suppresses any ‘cold
syndrome ’ that might otherwise have been expected to develop,
though it does not appear to influence the menstrual disturbance.
The question of the relation of menstrual disturbances to change
of weight is discussed by Kaboth,* though the obstetrical aspects
are not considered.
Other Symptoms.
Certain other symptoms, which might have been expected
from a study of the literature, were found less frequently or
not at all.
Marked emaciation occurred in only 2 patients (grade 4 and 3)
who lost 50 and go pounds weight respectively, and may be
regarded as cases of ‘ pituitary cachexia.’
Premature ageing was seen in 6 patients (3 in grade 5, 2 in
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
grade 4, and 1 in grade 3). Their general appearance was that ot
women 20 years older.
Severe anaemia sufficient to be easily recognized on inspection
of mucosae was present in 3 patients (grades 4, 2 and 1); these
patients did not show any other marked symptoms. The question
ot the relation of anaemia to the pituitary and other glands is
discussed by Snapper, Groen, Hunter and Witts.°
Anorexia was not found in a single case. This is in striking
contrast to its almost invariable occurrence in the pseudo-
Simmonds’s disease which is referred to later.
Two further points are recorded in the discussion below and
may be mentioned here. A case is noted as having had pyrexia if,
during the puerperium, the temperature reached 100.4°F. on any
occasion, whatever the cause. This point is taken into considera-
tion in view of the reputed importance of puerperal sepsis as a
cause of pituitary necrosis. In this connexion it is of interest
that, of 9 patients who developed femoral phlebitis or pulmonary
infarcts in the late puerperium, I was a grade 4 haemorrhage
collapse, I a grade 3, while the other 7 were only in grades I
and 2. These patients are now all in normal health, with the
exception of the first, who has definite evidence of pituitary
insufficiency.
Subsequent pregnancies have occurred in some of the patients,
even in those with rather marked symptoms, but most of the
patients have not had any further pregnancies. Sterility can, in
certain cases, be caused by pituitary malfunction either by inter-
ference with ovarian activity or by the destruction of libido. A
satisfactory conclusion cannot, however, be drawn from the inci-
dence of those pregnancies which occur, as this incidence is also
affected by two opposing but unmeasurable factors: (a) The
causes of the haemorrhage and collapse are most frequent in
multiparae. Multiparity often indicates that birth control is not
practised, either for social or for religious reasons. These reasons
usually remain as operative after a delivery with haemorrhage
and collapse as they were before it. (b) A delivery which is
nearly fatal from haemorrhage may cause so much fear of
subsequent pregnancy that the patient abstains completely from
coitus. In addition some of the patients have been sterilized at
operation.
CLASSIFICATION OF PATIENTS.
The individual patients can be divided into certain groups on
the basis of the symptoms just discussed. The relation of these
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
groups to the grade of haemorrhage collapse is shown in Table IV.
The details about the incidence of certain general symptoms in
each group are given in Table V.
Group A. Genital Atrophy. 8 cases.
All these patients have superinvolution of the uterus,
atrophy of the cervix to the size of a small button, negative iodine
reaction for glycogen in the vaginal mucosa, absence of acid or
of Déderlein’s bacilli in the vaginal secretion, and a shrunken
senile vulva. They have absolute amenorrhoea without molimina,
and subsequent pregnancy has never occurred. Flushings similar
to those of the menopause have been very troublesome in several
of the patients. These genital symptoms are presumably depen-
dent on lack of oestrin.
One of these patients has lost about 90 pounds in weight and
shows the clinical picture of Simmonds’s disease, and one patient
has developed into a full myxoedema. Mammary reaction was
absent in all the patients; the majority have a well-developed
cold syndrome, and many have lost body hair or show premature
senility. The ages of the patients range from 23 to 38 years.
The relation of this group to severity of haemorrhage collapse
is clear.
TaBLe IV.
Relation of clinical classification of patients to severity of haemorrhage
collapse at delivery.
Grade of haemorrhage
collapse
A Genital atrophy «. «.. 8 3 3
Menstrual disturbance ...... 18 6 5 3 4-
C Menstrual disturbance with
D Cold syndrome ... ... ... 9 —- 5
Absence of mammary reaction 20 4 6 7
G Normal 116 10 17 2 57
Total
(The figures in each column indicate the number of patients in the group
who had had haemorrhage collapse of that grade.)
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TABLE V.
Incidence of certain general symptoms in the various groups.
Classification of patients
Total cases 8 18 6 9 20 15 116
Absence of mammary reaction I —
Puerperal pyrexia . 4 I I 2 2 3.)
Cold syndrome:
Weight change:
Loss 15 to 30 pounds ..._... 2 4 -— 5 —- — 3
Loss 50 to go pounds ..._.. I — =
Gain 20 to 50 pounds .. —- 6 — 5 —
Body hair loss:
Moderate I —- —
Premature ageing 4 3 0- -
Subsequent pregnancy —_ 3 2 4 5 4 (15)
(The figures in each column indicate the number of patients in that group
who showed the symptoms.)
Group B. Menstrual Disturbance. 18 cases.
Eight of these patients had amenorrhoea for 9 to 18 months
post partum; menstruation then recommenced, but was only
occasional and at irregular intervals of 2 to 9 months or more.
In 6 cases a similar occasional menstruation is present, but the
initial amenorrhoea did not occur.
The other 4 patients had the initial long amenorrhoea; when
the menstruation recommenced it was regular but exceedingly
slight. Of these 4, 1 is only a borderline case as menstruation
has now become almost normal in amount.
The patients in this group do not have superinvolution of
the uterus or loss of iodine staining in the vagina; their genital
tract is still under oestrin control despite the menstrual disturb-
ance. The group shows a similar condition to group A, but in
a much milder form. The same general symptoms are present,
but with only half the relative frequency. The relation to
severity of haemorrhage collapse is also seen in this group.
Group C. Menstrual Disturbance with Adiposity. 6 cases.
Three of these patients have complete amenorrhoea; 2 had
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
initial amenorrhoea (up to 17 months) with subsequent occasional
menses at irregular intervals of about 3 or 4 months; the other
has similar occasional menses, but had no initial amenorrhoea.
This group is separated from group B because all the patients
show a marked gain in weight and, in association with this, are
all in excellent health physically and mentally. None of the
patients has any genital atrophy. There are only two general
symptoms of interest; 2 patients have complete loss of libido and
the majority had absence of mammary reaction.
The group shows a clear relation to the severity of haemor-
rhage collapse. The significance of this relation lies probably in
the fact that a patient must primarily have menstrual disturbance
in order to be included in this group. As explained in the
discussion on symptomatology the adiposity appears to be
unrelated to the haemorrhage collapse; it seems to be only a
accidental concomitant which changes the general clinical picture.
The menstrual disturbance is, however, just as marked as in
group B.
Group D. Cold Syndrome without Menstrual Disturbance.
Q cases.
In this group menstruation is not affected; otherwise the
patients show general symptoms similar to those in groups A
and B, but usually not so marked.
There is a definite relation to severe haemorrhage collapse,
but this is less evident, since most of the patients who have a
cold syndrome have also an associated menstrual disturbance,
and have therefore been included in groups A and B.
Group E. Absence of Mammary Reaction without subsequent
Symptoms. 20 cases.
These patients are only excluded from the normal group
because of the history of complete absence of breast activity in
the puerperium; 4 of them have minor degrees of ill-health, but
not sufficient to be considered significant in the present connexion.
There is some relation to haemorrhage collapse; none of the
cases occur in grade 0. It should be noted that the other 23 cases
without mammary reaction have already been classified in
groups A, B, C and D; these groups include most of the severe
cases of haemorrhage collapse.
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Group F. Adtposity. 15 cases.
This group is only separated from the normal group for
comparison with group C. There is not any relation to haemor-
rhage collapse, even taking group C into consideration.
Group G. Normal. 116 cases.
Three of these patients have menorrhagia due to subinvolution
or fibroids; one has some irregularity of menses, but not sufficient
to be considered a ‘ menstrual disturbance’; and two have minor
degrees of ill-health. Otherwise the patients in this group have
no symptoms dating from the delivery.
The bracketed figures in Table V for ‘‘puerperal pyrexia’”’
and ‘‘subsequent pregnancies’’ in this group refer only to the 59
patients with a history of haemorrhage collapse. The other 57
cases are from the control series, in which the data on these two
points are not strictly comparable and are therefore omitted.
This normal group shows an inverse relation to the severity of
the haemorrhage collapse.
Additional Cases.
Four cases of rupture of the uterus which necessitated
immediate hysterectomy have not been included in the series, as
the diagnosis is naturally complicated by the removal of the
uterus. The grade of haemorrhage collapse was 3 and 4 in these
cases. During the puerperium all of them had absence of
mammary reaction, but none had pyrexia. Complete amenor-
rhoea has, of course, continued since the delivery; 3 of the
patients have a definite cold syndrome, but their weight is
unchanged; the other patient is in good health.
Patients who have a severe haemorrhage and collapse at
delivery usually become comatose. The question thus arises as
to whether coma alone at delivery without any haemorrhage or
collapse can lead to a subsequent pituitary insufficiency. To
investigate this point a series of 29 cases of eclampsia was followed
up at I to 3 years after delivery. None of these patients had had
any haemorrhage or collapse at delivery, but all had had con-
vulsions and coma. In no case were any symptoms found
suggesting pituitary insufficiency. This series is also of interest in
that it does not give any support to the view that toxaemia may
predispose to pituitary insufficiency.
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
DISCUSSION.
SIGNIFICANCE OF SYMPTOMS.
In this follow-up, group A gives evidence of definite endocrine
insufficiency, while groups B, C and D show lesser degrees of a
similar condition. Groups E and F, on the other hand, have
minor disturbances which can scarcely be classed with those in
the previous groups. The endocrine insufficiency in groups A,
B, C and D can be most satisfactorily explained on general
physiological grounds as due to underfunction of the anterior
pituitary. This pituitary underfunction is a permanent condition;
it dates from a delivery complicated by haemorrhage collapse and
is Clearly related to the severity of the haemorrhage collapse.
This clinical finding is obviously linked up with the pathological
finding that the anterior pituitary often becomes necrosed after a
delivery complicated by haemorrhage collapse, and that the
frequency and size of these necroses are related to the severity of
the haemorrhage collapse. The significance of the comparison is
illustrated in Table VI, which shows: (a) The essential findings
in this clinical follow-up. (6) A summary of the pathological
findings discussed in the first part of this paper, but not including
minute necroses which would not produce symptoms. Most of
the percentages are calculated from figures too small to carry any
individual weight, but their general trend is clearly the same in
both series.
The most reasonable interpretation is that the patients in
group A have gross healed necroses of the anterior pituitary, and
that those in groups B, C and D have medium-sized healed
necroses. It is, however, not possible to conclude definitely that
healed pituitary necroses are present in all the patients in groups
A, B, C and D and in none of the patients in groups E, F and G.
(a) Only two cases with ‘‘pituitary cachexia’ were found. In
many of the other patients the symptoms, on which a diagnosis of
pituitary insufficiency was based, were often not very striking and
could not be considered at all specific if it were not known that
they began suddenly after a delivery with haemorrhage collapse.
Care has been taken to obviate as far as possible the error, which
is potentially inherent in any follow-up, of attributing too much
significance to borderline symptoms. Nevertheless, it must be
accepted that absolute proof of healed pituitary necrosis can only
be obtained at post-mortem examination. For instance, in
Case 2 of Usadel’ there were doubtful symptoms following an
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
abortion, but at post-mortem examination the pituitary did not
show any old lesion.
TaBLe VI.
Showing the similarity of relation of pituitary necroses and of pituitars
insufficiency to the grade of haemorrhage collapse.
CLINICAL.
Pituitary
underfunc-
Grade of tion; cases in
haemorrhage Total groups A, B, Per-
collapse cases C and D centage
5 12 II g2
4 29 17 59
3 30 9 30
2 31 4 13
26 oO oO
64 fe) fe)
PATHOLOGICAL.
Pituitary
Grade of necroses; com-
haemorrhage Total plete, large or Per-
collapse cases medium-sized centage
5 8 74 88
4 3 2 66
3 4 I 25
2 3 I 33
I 3 fe)
25
(b) On the other hand, it seems almost certain that a patient
with a small pituitary necrosis will be free of symptoms and be
passed as clinically normal. In animal experiments it is necessary
to remove at least two-thirds of the anterior pituitary to produce
recognizable malfunction. In human beings the diagnosis of
malfunction is probably easier, as subjective symptoms can be
ascertained and as menstruation can also be studied. It remains,
however, a matter of conjecture whether a patient can lose half of
the anterior pituitary and yet remain free from clinical symptoms.
There are in the literature a few cases in which the symptoms
corresponded to those of groups B or D in this follow-up and
where the pituitary was finally examined at autopsy. The
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
anatomical information from these cases is complicated by two
circumstances.
Firstly, it is not possible to say whether the remaining portion
of healthy pituitary may have hypertrophied or atrophied since
the original necrosis. Secondly, any illustration given is usually
only one section of the pituitary; to form any satisfactory concep-
tion of the size of the healthy remnant of anterior pituitary it would
be necessary to reconstruct the gland from serial sections. The
estimates given in the following list are based on the fact that, in
a mid-line section of the normal pituitary, the anterior lobe has
about three times the area of the posterior lobe. These estimates
are probably somewhat high because the necrosis usually spares
the region in front of the posterior lobe and beneath the stalk;
this region is included in the mid-line section which is usually
photographed. The significant cases are :—
Jakob,® Case 2. Necrosis of anterior pituitary after a difficult delivery
with post-partum haemorrhage at 36 years of age. Subsequent deliveries
at 37 and 39 and a menstrual period at 41 years of age. Died at 41. At
autopsy the anterior pituitary was represented by a few very small areas
of live tissue and a band along the middle lobe. The illustration is not
good enough for detailed measurements.
Sheehan,! Case 12. Necrosis of anterior pituitary at 37 years of age
due to retained placenta with severe haemorrhage collapse. Pregnancy
began 9 months later; she died at delivery owing to retained placenta and
severe post-partum haemorrhage. At autopsy the live remnant of the
anterior pituitary was to to 15 per cent of the normal.
Richter.® Necrosis of anterior pituitary at 32 years of age when she had
a delivery followed by puerperal fever. Menstruation continued till 40
years of age. She died aged 62 years. At autopsy there were small groups
of cells remaining alive in the anterior pituitary, but no illustration is given.
Heinrichs.'° Necrosis of anterior pituitary at 33 years of age due to
severe haemorrhage at her ninth delivery. She had a definite cold syndrome,
but menstruation was regular for a time, then became infrequent and
finally ceased at 35 years of age. She died aged 36 years. At autopsy the
live remnant of the anterior pituitary was about 15 to 20 per cent of the
normal,
Kaminski,!1 Case 2,.and Reye and Sciirmann.!* Necrosis of anterior
pituitary at 28 years of age due to retained placenta and uterine atony with
severe haemorrhage and collapse. She had irregular menses during the next
3 years and then developed into a complete Simmonds’s disease. She died
aged 58 years. At autopsy there was practically no anterior pituitary tissue
remaining, though the pars intermedia was still recognizable.
In the present follow-up there is a further point which is
difficult to interpret satisfactorily. Any severe case, such as in
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
group A, shows most of the significant symptoms. In the lower
groups, however, there is a curious dissociation; the patients can
have any single symptom or any combination of symptoms. The
explanation may be on various lines : —
(a) The part of the pituitary which escapes necrosis is not
necessarily the same in all cases; different parts of the pituitary
have different cell-ratios and may possibly have different
functions.
(b) There may be variations of sensitivity of different endo-
crine glands to tropic hormones from the pituitary in different
individuals.
(c) There may be basic variations in the activity of the
different endocrine glands, either intrinsic or under the influence
of non-pituitary tropic factors.
In the absence of any direct evidence, further speculation
about this question does not appear of value.
PARITY, AGE AND OBSTETRICAL COMPLICATION.
Textbook descriptions of Simmonds’s disease sometimes stress
the common occurrence of the disease in old multiparae. In this
follow-up the patients with symptoms of pituitary necroses were
often rather elderly multiparae at the time of the significant
delivery. This association appears, however, to be due only to
the increasing frequency of haemorrhage and collapse with
increasing parity and age. The relevant data are summarized in
Table VII.
Taste VII.
Relation of parity and age at time of significant delivery to occurrence of
collapse and to development of pituitary insufficiency
Percentages
Parity Age
2 4 and
and 3. ovef 15-24 25-29 30-45
Patients with pituitary insufficiency.
Groups A, B, C and D—41 cases 27 61 58
All patients with haemorrhage col-
lapse in this follow-up—128 cases 30055 64
‘‘Haemorrhage deaths’’ in this hos-
pital—1oo cases . 1965 67
General admissions to this hos-
pital—350 cases 34 31 34
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
Table VIII shows that there is not any correlation in this
follow-up between the actual cause of the haemorrhage collapse
and the clinical evidence of pituitary necrosis. All the patients
had deliveries at or near full time; a follow-up was not made of
abortions or ectopic pregnancies.
VIII.
Showing that the actual cause of the haemorrhage collapse at delivery is
not significant.
Cause of ~ Total Cases in groups
haemorrhage collapse cases A, B, C and D
Retained placenta
Accidental haemorrhage Bn 37 10
Placenta praevia
Post-partum haemorrhage, or
' obstetric shock, or rupture of
uterus
Second Follow-up. Investigation of Previous History of Patients
with Symptoms Suggestive of Pituitary Insufficiency.
The last follow-up was limited to one direction; it gave data
only as to how many patients, who had had haemorrhage collapse
at delivery, subsequently developed pituitary insufficiency. A
second follow-up was therefore made, approaching the problem
from the opposite angle. Its purpose was to ascertain how many
parous women with symptoms suggesting pituitary insufficiency
had a history that these symptoms developed after a delivery,
and whether or not this delivery was complicated by haemorrhage
collapse.
As it was desired to study only those patients who had
presumptive indications of pituitary insufficiency, no attempt was
made to collect borderline cases. The primary criterion for
inclusion in this follow-up was the occurrence of amenorrhoea or
very infrequent menses without any obvious local or general
explanation. The follow-up was limited to parous women, but
selection was not made on the question of whether or not the
symptoms dated from a delivery. Fifteen cases* with menstrual
disturbance of this type were collected from several local hospitals.
* Thanks for assistance in collecting these 15 cases are due to the. follow
ing: Drs. Crawford, Hart, Hendry, Hewitt, Hunter, MacIntyre, MacLennan,
Morton, and Sharman.
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They were first investigated clinically and then the history of the
condition was elicited; as this history was obtained only from the
patient herself it is often incomplete, but the details are sufficient
for the present purpose. The cases are divided into groups A, B
and C on exactly the same basis as in the previous follow-up; an
idiopathic group is also included.
Group A. Genital Atrophy. 4 cases.
The first 2 cases may be described in some detail, as they give
fairly typical pictures, the first of Simmonds’s disease and the
second of post-partum myxoedema.
Case 3. Aged 47 years, 3-para. Complete amenorrhoea and complete
loss of pubic and axillary hair. Marked cold sensitivity and physical weak-
ness almost to the state of being bedridden. Mental deterioration and great
apathy with a negativistic attitude which prevented any investigation of the
condition of the genitalia. Delusions had been present for the past 2
months. Slow speech with a peculiar accent, and tailing off to complete
inaudibility towards the end of any sentence. Dry, pale skin; face wizened
and haggard so that she looks more than 65 years of age. Some loss of
weight but no emaciation. Basal metabolic rate —28 per cent, achlorhydria,
anaemia.
All the symptoms began suddenly after the last delivery 11 years pre-
viously when she had a very severe haemorrhage and was dangerously ill.
Case 4, aged 37 years, 2-para. Complete amenorrhoea, superinvolution of
the uterus and senile vulva but normal glycogen in vaginal mucosa. Loss
of all axillary and pubic hair except over the labia. Absence of libido.
Polydypsia and polyuria. Loss of about 25 pounds in weight within a year,
since which she has slowly regained about 7 pounds weight. Waxy pallor of
face. Occasional rheumatic swelling of knees, blood-pressure go/65, achlor-
hydria, moderate anaemia. For the first 2 years she had in addition the
following symptoms: marked cold sensitivity and muscular weakness, strik-
ingly myxoedematous appearance of face, thick dry skin, mental torpor,
slow speech, loss of head hair and eyebrows, basal metabolic rate —47
per cent. This last group of symptoms has been much ameliorated by
thyroid treatment for the last 4 years, though she is still rather weak and
unable to do housework.
All the symptoms began suddenly after her last delivery 6 years pre-
viously when she had a very severe post-partum haemorrhage due to re-
tained placenta. She was unconscious for several hours. Mammary reaction
was absent in the puerperium.
Case 5, aged 33 years, 5-para. Complete amenorrhoea, superinvolution
of the uterus, absence of glycogen in vaginal epithelium, no acid or Déderlein
bacilli in vaginal secretion, senile vulva. Marked loss of axillary and pubic
hair, Severe cold syndrome but no loss of weight.
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
The symptoms began suddenly after a delivery 4 years previously; exact
details about this are not available as she became unconscious during the
third stage of labour and only recovered a long time after the placenta
was delivered. There was no swelling of the breasts during the puerperium;
she had symptoms suggesting a mild puerperal sepsis. Nine months after
the delivery she had one slight uterine haemorrhage with pain.
Case 6, aged 28 years, 1-para. The condition of this patient is the same
as Case 5 except that there is not any loss of body hair.
The symptoms began suddenly after a delivery 5 years previously when
she had very severe haemorrhage due to placenta praevia.
Group B. Menstrual Disturbance. 3 cases.
In each of these cases the uterus is small, but the vaginal
epithelium contains glycogen and the vaginal secretion is acid.
Case 7, aged 20 years, 2-para. Complete amenorrhoea, but she has
recently had molimina. She has lost 30 pounds in weight but has no cold
syndrome.
The symptoms began suddenly after a delivery one year previously when
she had severe post-partum haemorrhage but did not become unconscious
The breasts became swollen in the early puerperium.
Case 8, aged 36 years, 8-para. Amenorrhoea for 7 months followed by a
return of regular menses and a further pregnancy. For the 12 months since
this second delivery there has been complete amenorrhoea. She has a weil-
marked cold syndrome, a weight loss of 70 pounds, and some diarrhoea.
The symptoms began suddenly after a twin delivery 3 years previously
when she had very marked post-partum haemorrhage. There was no mam-
mary reaction in the puerperium. In the last delivery she had an accidental
haemorrhage and was very seriously ill.
Case 9, aged 34 years, I-para. Amenorrhoea for 4 years, followed by
three slight menses, since which there has again been complete amenorrhoea
(6 months). Otherwise well.
The symptoms began suddenly after a delivery 434 years previously
when she had much haemorrhage due to a placenta praevia, and also post-
partum haemorrhage.
Group C. Menstrual Disturbance with Adiposity. 6 cases.
In case 10 the uterus is normal in size; in case 15 it is
enlarged owing to a polypus in its cavity; in the other cases the
uterus is rather small. The vagina is normal in all.
Case 10, aged 25 years, I-para. Occasional menses at intervals of 1 to
12 months: in all, 8 menses in 4 years. Her weight increased rapidly by
40 pounds, but otherwise she is quite well.
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The symptoms began suddenly after a delivery 4 years previously when
she had severe post-partum haemorrhage. She lactated for 2 months after
the delivery.
_ Case 11, aged 23 years, I-para. Complete amenorrhoea without molimina
Rapid increase of 25 pounds in weight following delivery; otherwise well.
The symptoms began suddenly after a delivery 1 year previously when
she says she had no haemorrhage or sepsis.
Case 12, aged 24 years, 2-para. Amenorrhoea for 17 months, then one
menstrual period, and since then (35 months).amenorrhoea. Rapid increase
of 30 pounds in weight following delivery. She felt rather lazy until recently
but is otherwise quite well,
The symptoms began suddenly after a delivery 4% years previously.
Details about this delivery are lacking as she became unconscious during
the third stage of labour and remembers nothing for several hours later.
The temperature was normal during the puerperium, but there was not any
mammary reaction.
Case 13, aged 29 years, 1-para. Amenorrhoea without molimina. Her
weight has increased by 40 pounds and there is the unusual complaint of
increased sensitivity to cold and some asthenia. Otherwise she is well.
The symptoms began suddenly after a difficult operative delivery with
cervical incisions 214 years previously when she had very severe haemor-
rhage. There was swelling of the breasts during the puerperium and
possibly some pyrexia.
Case 14, aged 34 years, 13-para. Amenorrhoea without molimina. Rapid
increase of 20 pounds in weight. Some asthenia and increased sensitivity to
cold, but otherwise well.
The symptoms began suddenly after an abortion 11; years previously
when she had very severe haemorrhage and some sepsis.
Case 15, aged 30 years, I-para. Menses at irregular intervals of 3 to 10
months but rather profuse, possibly as a result of the polypus. Rapid gain
of 25 pounds weight, but otherwise quite well.
The symptoms began suddenly after a difficult forceps-delivery 6 years
previously when she had severe post-partum haemorrhage. There was uc
mammary reaction during the puerperium.
Idiopathic Pseudo-menopause. 2 cases.
Case 16, aged 40 years, 3-para. At 32 years of age menstruation became
slighter and less frequent, it decreased steadily for a year and then became
a complete amenorrhoea.
There is no relation to any pregnancy; the three deliveries were normal
Case 17, aged 29 years, I-para. Gradual diminution of menstruation for
last 3 years; now almost complete amenorrhoea.
The symptoms are not related to the previous delivery, which was
normal.
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
DISCUSSION.
The clinical condition and history in cases 3 to 15 are in
obvious agreement with those in Groups A, B and C in the first
follow-up. It can be presumed that in these 13 cases a necrosis
of the anterior pituitary occurred at the last delivery. It must
be emphasized that in this follow-up the history of the significant
delivery was provided only by the patient; information could not
be obtained from anyone else present at the delivery in the
anomalous case II or in cases 5 and 12. In these latter 2 cases
the unconsciousness in the third stage of labour was probably
due to post-partum haemorrhage from retained placenta.
Cases 16 and 17 are clearly examples of a quite unrelated
condition; their menstrual disturbance was of gradual develop-
ment and had no relation to delivery. The aetiology of this is
not clear, but there is no evidence to indicate that it is due to
any pituitary lesion. These two cases are included only to com-
plete the record of the series investigated.
The number of cases in this follow-up is rather small for defi-
nite conclusions based on the series alone, but with the support
of the findings in the first follow-up it seems reasonable to
consider that symptoms of pituitary insufficiency in parous
women are in many cases indicative of an old necrosis of the
anterior pituitary due to haemorrhage collapse at delivery.
Literature.
Pathological.
A review has been given elsewhere (Sheehan') of most of the
reported cases in which there is autopsy proof of. post-partum
necrosis of the anterior pituitary, either recent or healed.
References were also given to certain other pathological condi-
tions which may show a superficial similarity to the post-partum
lesion and must, therefore, be carefully differentiated from
it. The following cases should be added to the lists given in that
paper.
TypicaL HEALED Post-PARTUM NECROSES FOUND AT AUTOPSY.
Richter. F.62, 6-para. Symptoms since last delivery 30 years before.
when she had puerperal fever. No other obstetric data.
Heinrichs.!° F.36, 9-para. Symptoms since last delivery 3 years before,
when she had sever? haemorrhage.
Usadel.? Case 1. F.38, 1-para. Symptoms since the delivery 11 years
before. The delivery was difficult and was accompanied by severe haemor-
rhage. ;
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Gallavan and Steegman.!* Case 1. F.51, 2-para. Symptoms since last
delivery 5 years before. This delivery was difficult but no other information
is given about it.
Gallavan and Steegman.!3 Case 2. F.60, 7-para. Symptoms since last
delivery 28 years before, when she had toxaemia; no other obstetric data.
Bini.'4 F.47, 7-para. Symptoms since last delivery 19 years before,
when she had ante-partum eclampsia. According to her sister the delivery
was otherwise normal.
DousBtFuL HEALED NECROSES.
Berblinger.'5 F.66. Massive connective tissue replacement of the front
and sides of the anterior pituitary. Died of thyroid sarcoma. Obstetric
history not given.
Boller and Goedel.4 Case 1. F.51. Doubtful healed necrosis of anterior
lobe with some fibrosis. Severe symptoms only for last year but menopause
at 35 years of age. No obstetric history given.
Boller and Goedel.4 Case 2. F.69, 3-para. Doubtful healed necrosis of
anterior lobe. Severe symptoms only for last 2 years. No history of any
relation of symptoms to delivery.
TRUE FIBROSIS OR GROSS SCARRING OF ANTERIOR PITUITARY.
These are entirely different pathological conditions and are unrelated to
pregnancy.
Cagnetto.!® Case 3, M.80; Case 5, M.41, syphilis; Case 6, M.72; Case 7,
M.47; Case 8, M.33, syphilis; Case unnumbered, M.48, syphilis.
Faure-Beaulieux, Villaret and Sourdel.!7 M.58, syphilis.
von Monakow,}® M.58. Frankel,!® M., syphilis. Parhon and Briesse,?°
insane patients. Dimmel,?! M.28. Strauss and Globus,?? F.53. Werthemann,?*
Case 3b. Nielsen,?4 two cases (?). Hantschmann,?> M.35. Rdéssle,2® M.26
and F.52.
RECENT NECROSIS OF ANTERIOR PITUITARY, NOT RELATED TO PREGNANCY.
Forlini,?’ diphtheria.
Clinical.
Though the aetiology has only been explained recently, the
clinical aspects have been known and described for a century or
more as superinvolution of the uterus (in contradistinction to
lactation-atrophy), or as premature menopause, or as myx-
oedema developing after pregnancy with haemorrhage (see Hun
and Prudden*), or more recently as Simmonds’s disease. A
review of the clinical aspects must inevitably be incomplete as an
attempt cannot be made to survey all the cases reported in the
older literature.
One very striking paper by A. R. Simpson’ deserves, how-
ever, to be quoted. In reporting 22 cases of superinvolution of
480
POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
the uterus, he noted that the most fruitful cause of superinvolu-
tion was the complication of the antecedent labour or abortion
with a pronounced haemorrhage, sometimes unavoidable or
accidental but more frequently in the third stage or post partum.
In some of his patients there was amenorrhoea since the delivery;
in others there was a menstrual discharge very slight in amount
and short in duration or recurring at prolonged intervals. There
was sometimes sterility or loss of libido. In some patients there was
a marked diminution in the intellectual powers, or a thickness
and hesitancy of utterance, or general drowsiness, or unsteadi-
ness of gait, or in a few cases puerperal insanity. Most of the
patients were thin and tabetic but in a few cases the patient was
unusually stout. In one or two the appearance resembled that of
sufferers from myxoedema, and one patient developed Addison’s
disease. J. Y. Simpson*® had previously described the syndrome
that develops in cases of post-partum superinvolution of the
uterus; he noted the amenorrhoea and sterility, the loss of sub-
cutaneous fat, the atrophy of breasts, the withering and wrinkling
of skin and appearance of progeria, the depression and impaired
activity of the mind, the anaemia, the general debility and the
ease with which the patients became fatigued. Frommel*' also
remarked on the progeria and poor nutrition of many of his
cases of superinvolution of the uterus. More recent discussions
of post-partum pituitary insufficiency are given by Reye,”
Niirnberger,** Seitz,** Reye,** Kehrer,** and Jumon.*’
A summary is given below of reports in the modern literature
of clinical cases in which a condition suggesting pituitary insuffi-
ciency followed a delivery. In a few of these cases the patient
died but the pituitary was not examined; the other patients were
still alive at the time the case was published. All of these cases
appear to be examples of healed post-partum necroses of the
anterior pituitary, though pathological proof is not available.
Many of the more severe cases were diagnosed as Simmonds’:
disease, those with gross evidence of thyroid insufficiency were
reported as myxoedema, while others with less marked general
symptoms were reported as superinvolution of the uterus or post-
partum emaciation. To avoid duplicating the descriptions, the
cases are classified here in the same groups as the follow-up
series; the classification is reasonably correct though in a few
instances the information available is insufficient for absolute
accuracy.
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Group A.
Brissaud and Bauer.** F.29, 1-para. Symptoms since the delivery 9
years previously. Obstetric data, except that labour was premature, absent.
Goullioud and Poncin.**. F.37, 4-para. Symptoms since last delivery
when she had severe haemorrhage and collapse.
Hertoghe.*®. F.39. Symptoms since last delivery 214 years previously
Obstetric data absent.
Veil.41 Case 1. F.38, 5-para. Symptoms since last delivery when she
had severe haemorrhage.
Lichtwitz.42 Case 3. F.41, 2-para. Symptoms since last delivery 16
years previously when she had puerperal pyrexia. Obstetric data absent.
Borchardt.‘* F.41, 5-para. Symptoms since last delivery 14 years pre-
viously when she had severe haemorrhage and puerperal pyrexia.
Reye.®?.. Case 3. F.36, 1-para. Symptoms since the delivery 4 years
previously when she had very severe haemorrhage.
Suchier.44 F.21. Symptoms since delivery 1 year before when there
was manual removal of the placenta and severe haemorrhage.
Rowe and Lawrence.‘* F.35, 3-para. Symptoms since complicated
labour 3 years previously.
Farquharson and Graham.'® Case 1. F.40. Symptoms since delivery
8 years previously when she had puerperal pyrexia. Obstetric data absent.
Farquharson and Graham.'* Case 3. F.38, 4-para. Symptoms since
last delivery 10 years previously. The delivery was difficult but no other
details are given.
Hoet.*7 Case 1. F.30, 2-para. Symptoms since last delivery. Obstetric
data absent.
Clauberg.48 Case 2. F.37, 1I-para. Symptoms since the delivery 13
years previously. Obstetric data absent.
Schachter.4®. F.28. Symptoms since last delivery when she had severe
haemorrhage and collapse which necessitated blood transfusion.
Rau.*° F.56, 3-para. Symptoms since last delivery 20 years previously.
The labour is recorded as normal.
Snapper, Groen, Hunter and Witts.6 Case 2. F.43, 3-para. Symptoms
since last delivery 15 years previously. This was complicated by severe
bleeding.
Ehrhardt and Kittel.5' Case 9. F.28. Symptoms since a miscarriage
for which curettage was required.
Group B.
Carli.6? Case 3. F.26, 3-para. Symptoms since last delivery when she
had severe haemorrhage.
Reye.°? Case 2, and *4, Case 2. F.35, 6-para. Symptoms since last
delivery 7 years previously when she had severe haemorrhage but no sepsis.
Reye.*? and 54 Case 3. F.35, 2-para. Symptoms since last delivery 2
years previously when she had manual removal of the placenta and post-
partum haemorrhage.
Curschmann.*> Case 2. F.39, 9-para. Symptoms since last delivery
10 months previously. Obstetric data absent.
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POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
Constantini.®* F.54, 8-para. Symptoms since last delivery 20 years
previously when she had severe haemorrhage.
Hiirthle.** Four cases following delivery.
Seitz.34 F.23. Symptoms since delivery when she had some post-partum
haemorrhage.
Guggisberg.°* F. 26, 3-para. Symptoms since last delivery which was
normal.
Wilson.®® Case 2. F.37. Symptoms since delivery.
Wilson.** Case 1. F.29. Doubtful case following normal delivery.
Gardiner-Hill and Smith.*° Table VII, case 2. F.52. Doubtful case.
Amenorrhoea since delivery 14 years before. Obstetric data absent.
Ebrhardt.*! F.35. Doubtful case following operation for ectopic preg:
nancy 14 years previously.
Group D.
Curschmann.*? Case 2 and °° Case 1. F. 27, 1-para. Symptoms since
the delivery. Obstetric data absent.
Lucke.®*?a F.40, 4-para. Symptoms since last delivery which was an
abortion with sepsis.
DISCUSSION.
In the above lists, together with the lists given previously
(Sheehan, 1937), there are records of 27 cases with pathological
evidence of healed post-partum necrosis of the anterior pituitary
and of 34 cases with clinical evidence of the same condition. It
will be noted that only 25 have a history of haemorrhage collapse
at delivery. The comparative rarity with which this obstetrical
condition is recorded is not of very great significance. Obstetric
histories are often not given or are imperfect; as a result of the
original theory as to aetiology, authors have usually paid more
attention to eliciting a history of any puerperal sepsis than of any
haemorrhage or collapse at delivery. In the cases of Bini, Rau,
Guggisberg and Wilson the labour is reported as normal; these
4 cases would be of greater importance if a definite statement
were made that haemorrhage or collapse had not occurred. There
is not, however, any evidence that a detailed investigation of this
point was made; delivery took place very many years pre-
viously, and information is lacking as to whether the history of
the delivery was obtained from a reliable source.
DIFFERENTIAL DIAGNOSIS.
Clinical evidence of pituitary insufficiency may be due to
various causes :
(a) Surgical hypophysectomy, as in the cases described by
Moricard™ and Eldon.
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(6) Post-partum necrosis of the anterior pituitary as discussed
in this paper.
(c) Scarring or fibrosis of the anterior pituitary, due in many
cases to syphilis or trauma.
(d Tumours, cysts or granulomata in the pituitary. These
sometimes give evidence of pressure on neighbouring structures,
e.g. diabetes insipidus. Occasionally, in these cases, symp-
toms either of underfunction or of overfunction of the anterior
pituitary may become prominent during or after pregnancy. If
underfunction develops it may be due to an associated post-
partum necrosis, but such a diagnosis is naturally very uncertain.
Cases of interest in this connexion are described by Lichtwitz,**
Case 2, Keilmann,’ Lévi,** Winter,*’ Khavine,** Reckmann,*
and Snapper, Groen, Hunter and Witts,° Case 3. The case of
Lichtwitz is discussed critically by Reiche.”
(e) Functional disturbances. In recent years numerous
reports have been published of cases clinically diagnosed as
Simmonds’s disease in which there is no evidence suggesting any
organic pituitary lesions of the types mentioned above. In a
few of these cases the symptoms point strongly to a true pituitary
insufficiency; in some cases the diagnosis of Simmonds’s disease
appears to be merely a label for cachexia of unknown origin; in
most of the cases the diagnosis is based only on the general
endocrine disturbance that develops in the course of anorexia
nervosa (see Ryle,”’ Berkmann”’). Commonly the patient is an un-
married woman about 15 to 25 years of age; the primary symp-
toms are usually psychic disturbance and anorexia followed by
emaciation; there is often an associated amenorrhoea and
lowering of the basal metabolic rate. A cure can be obtained by
various treatments ranging from psychotherapy to the subcu-
taneous implantation of an animal pituitary.
Purely functional insufficiency of the anterior pituitary is an
obvious and important possibility in endocrine pathology, but
the clinical diagnosis should be very circumspect. A similar
attitude is required when a patient, who had symptoms which
might possibly suggest a pituitary insufficiency, is found at post-
mortem not to have any gross lesion of the pituitary, any histo-
logical change described being only cytological. While cytology is
clearly of fundamental importance in the study of function, its
interpretation is not easy in dead tissues in view of the possible
occurrence of purely terminal cellular disturbance or of post-
mortem autolysis. Cases in which the pituitary did not show any
484
POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
gross lesions are recorded by Popper,”* Azerad,”* de Gennes,
Delarue and Rogé,’° Kylin,”* Case 22, and Hubschmann.”
The whole subject of possible functional pituitary insufficiency
is of great interest, but it must be sharply distinguished from
true organic insufficiency. The recent literature on the subject
is noted in the Appendix. This list includes many cases reported
as Simmonds’s disease without any satisfactory evidence that the
pituitary was affected, a few cases in which the diagnosis appears
justified but the aetiology is obscure, and discussions as to
whether or not the anterior pituitary plays any role in anorexia
nervosa.
SUMMARY.
Post-partum ischaemic necrosis of the anterior pituitary is of
relatively frequent occurrence. It is caused by collapse of the
patient, usually as a result of haemorrhage, at or about the time
of delivery. It can be found pathologically in its early stage if
the patient dies in the puerperium, or in its healed stage if death
occurs some years later. If the patient survives the puerperium,
clinical evidence of pituitary insufficiency may develop subse-
quently; this can be of any degree of severity from general
debility to superinvolution of the uterus or, in its most extreme
form, to the cachexia known as Simmonds’s disease.
Two cases of the early stages of the necrosis are described.
This condition has been found at post-mortem in 13 out of 46
women who died in the puerperium later than 14 hours after
delivery. There is a definite relation between the frequency and
size of the necroses and the severity of the haemorrhage collapse.
A follow-up of 128 patients who had had various degrees of
haemorrhage collapse at delivery some years previously showed
that in 41 cases there were symptoms suggesting pituitary insuffi-
ciency which dated from the delivery. There is a definite relation
between the frequency and severity of the present symptoms and
the severity of the haemorrhage collapse at the delivery. It is
concluded that, in the 41 cases, the symptoms are due to healed
post-partum necroses and are proportionate in severity to the
extent of these necroses (see Table VI).
A reverse follow-up of 15 parous women who had symptoms
suggesting pituitary insufficiency showed that in 13 of them the
condition dated from a delivery in which there was severe haemor-
rhage collapse. It is concluded that in these 13 cases the
symptoms are due to healed post-partum necroses.
The relevant literature is reviewed.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
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=
13
14
: 15
«16
17
18
19
20
21
22
23
24
25
26
27
29
31
32
33
34
; 35
36
37
39.
40
41
42
43
61.
62.
POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
. Suchier, W. Miinch. med. Wschr., 1927, \xxiv, 1795.
. Rowe, A. W., and C. H. Lawrence. Quoted by Silver, 1933.
. Farquharson, R. F., and D. A. L. Graham. Trans. Assoc. Amer. Phys,,
1931, xlvi, 150
- Hoet, J. P. Bull. Acad. Méd. Belg., 1933, xiii, 445.
. Clauberg, C. Z. Gebuntsh. Gynidk., 1934, Cvii, 331.
. Schachter, M. Gynéc. et Obstét., 1935, Xxxii, 77.
. Rau, L. Lancet, 1935, i, $502.
. Ehrhardt, K., and C. Kittel. Z. klin. Med., 1937, cxxxli, 246.
. Carli, G. Arch. ital. Ginecol., 1907, x, 193.
. Reye, E. Dtsch. med. Wschr., 1928, liv, 696.
. Reye, E. Zbl. inn. Med., 1931, lii, 946. 4
. Curschmann, H. Z. drztl. Fortbild., 1929, xxvi, 409.
. Constantini, F. Policlinico, 1931, xxxvili, 251.
. Hiirthle, R. Med. Klinik, 1932, xxviii, 1637.
. Guggisberg, H. Schweiz. med. Wschr., 1936, xvii, 34.
. Wilson, J. St. G. Lancet, 1936, i, 951.
. Gardiner-Hill, H., and J. F. Smith. Journ. Obstet. and Gynaecol. Brit.
Emp., 1927, xxxiv, 701.
Ehrhardt, K. Miinch. med. Wschr., 1929, 1xxvi, 1246.
Curschmann, H. Mschr. Geburtsh. Gynik., 1930, Ixxxvi, 253.
62a. Lucke, H. Klin. Wschr., 1932, xi, 1988.
63.
64.
65.
66.
67.
. Khavine, J. B. Rev. Frang. Endocrin., 1936, xiv, 307.
. Reckmann, R. Arch. Gynikol., 1936, clx, 454.
. Reiche, F. Med. Klinik, 1927, xxiii, 1569.
. Ryle, J. A. Lancet, 1936, ii, 892.
. Berkman, J. M. Journ. Amer. Med. Assoc., 1936, Cvi, 2042.
. Popper, L. Med. Klinik, 1933, xxix, 1644.
. Azerad. Bull, Soc. Méd. H6p. Paris, 1936, lii, 1524.
. de Gennes, L., J. Delarue, and Rogé. Buli. Soc. Méd. Hép. Paris, 1936.,
Moricard, R. Bull. Soc. Obstét. Gynécol. Paris, 1936, xxv, 777.
Elden, C. A. Endocrinology, 1936, xx, 679.
Keilmann, K. Zbl. allg. Path. path. Anat., 1922, xxxiii, 113.
Lévi, L. Rev. Neurol., 1922, xxix, 705.
Winter, E. W. Arch. Gynidkol., 1931, cxlvii, 95.
lii, 387.
. Kylin, E. Klin. Wschr., 1936, xv, 1756.
. Hubschmann, H. Miinch. med. Wschr., 1937, \xxxiv, 697.
Silver, S. Arch. Intern. Me2d., 1933, li, 175.
APPENDIX.
Abel, E., and P. Kissel. Rev. frang. Endocrin., 1934, xii, 287.
Alberdi y Goni, J. M. An. Med. Interna., 1934, iii, 27; abstract in Zb/. ges
Neurol. Psychiat., 1934, \xxii, 421.
Albo, W. L. An. Med. Interna., 1934, iii, 707; abstract in Zbl. ges Neurol
Psychiat, 1935, \xxiv, 703.
Aldrich, C. A., and J. A. Walsh. J. Pediat., 1935, vii, 491
Augier, P., and P. Cossa. J. Méd. franc., 1936, xxv, 356.
487
44
45
46
47
48
49
50
st
52
53 a
54
56
57 :
5
5
77
=
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Baltzan, D. M. Canad. Med. Assoc, Journ., 1937, xxxvi, 64.
Belaiche, M. These, Paris, 1933.
von Bergman, G. Dtsch. med. Wschr., 1934, |x, 123.
Bickel, G. Pr. Méd., 1936, xliv, 1204.
Baenheim, F., and F. Heimann. Dtsch. med. Wschr., 1930, lvi, 1818.
Bulger, H., and D. P. Barr. Endocrinology, 1936, xx, 137.
Cahane, M., and T. Cahane. Ann. Méd.-psychol., 1936, xciv (2), 798;
abstract in Zentralb. ges. Neurol. Psychiat., 1937, \xxxv, 208.
Cervera, L., A. Folch, and R. Benaiges. Rev. Franc. Endocrin., 1934,
xii, 15; Rev. Frang. Endocrin., 1937, XV, 291.
Dunn, C. W. Journ. Nerv. Ment. Dis., 1936, \xxxiii, 166.
de Gennes, L. Bull. Soc. Méd. Hép. Paris, 1936, lii, 1519.
Grafe, E. Deutsch. med. Wochenschr., 1932, lviii, 576.
Hawkinson, L. F. Journ. Amer. Med, Assoc., 1935, Cv, 21.
Hellenthal, E. Miinch. med. Wochenschr., 1936, Ixxxiii, 1312.
Herman, K. Miinch. med. Wochenschr., 1934, \xxxi, 1460; Amer. Journ.
Digest. Dis., 1936, iii, 382.
Hicks, C. S., and F. S. Hone. Proc. Roy. Soc. Med., 1935, xxviii (2), 925.
Kalk, H. Deutsch. med. Wochenschr., 1934, 1x, 893.
Kissling, K. Miinch. med. Wochenschr., 1932, \xxix, 655.
Krause, Fr., and O. H. Miiller. Klin. Wochenschr., 1937, xvi, 118.
Kylin, E. Klin. Wochenschr., 1936, xv, 1756; Med. Klinik, 1937, xxxiii,
1497.
Loeper, M., and R. Fau. Monde Méd., 1936, xlvi, 921.
Lucacer, M. Rif. Med., 1932, xlviii, 547.
McGovern, B. E. Endocrinology, 1932, xvi, 402.
Mainzer, F. Schweiz. med. Wochenschr., 1937, \xvii, 513.
May, E., and P. Robert. Ann. Méd., 1935, xxxviii, 317.
Menzel, W. Miinch. med. Wochenschr., 1937, \xxxiv, 969.
Merklen, P., M. Aaron, L. Israel, and A. Jacob. Bull. Soc. Méd. Hop.
Paris, 1936, lii, 1360; Progr. Méd., 1936, Ixiii, 1849.
Moehlig, R. C. Endocrinology, 1936, xx, 155.
Parhon, C. I., A. Kreindler, and E. Weigl. Ann. Méd.-psychol., 1936, xciv,
352.
Randall, L. M., and D. G. Drips. Proc. Mayo Clinic, 1937, xii, 340.
Ravenel, S. F. Sth. Med. Journ., Nashville, 1937, Xxx, 403.
Regester, R. P., and T. D. Cuttle. Endocrinology, 1937, xxi, 558.
Riecker, H. H., and A. C. Curtis. Journ. Amer. Med. Assoc., 1932, xcix, 110
Rothmann, H. Acta. Med. Scand., 1935, \xxxvii, 168.
Rougean, R., and M. Rougean. Ann. Méd.-psychol., 1937, xcv (1), 634.
Schiipbach, A. Schweiz. med. Wochenschr., 1936, \xvi, 1245.
Schur, M., and C. V. Medvei. Wien. Arch. inn. Med., 1937, xxxi, 67.
Selander, P. Hygiea, Stockh., 31934, xcvi, 125. Abst. in Zentralb. ges
Neurol. Psychiat., 1934, \xxii, 730.
Shaw. M. Proc. Roy. Soc. Med., 1935, xxviii, 1176.
Steinitz, E., and E. Thau. Ther. d. Genenw., 1932, |xxiii, 296.
Stocks, J. W. Lancet, 1930, ii, 349.
Striker, C. Journ. Amer. Med. Assoc., 1933, ci, 1094.
Stroebe, F. Zentralb. f. Gynikol., 1935, lix, 1156.
>
POST-PARTUM NECROSIS OF THE ANTERIOR PITUITARY
Stroebe, F., and others. Med Klinik., 1936, xxxii, 859, etc.
Thompson, W. O. Journ. Amer. Med. Assoc., 1933, Ci, 1994
Vogt, E. Med. Klinik, 1935, xxxi, 1393.
Wachstein, M. Klin. Wochenschr., 1934, xiii, 1434.
Wahlberg, J. Acta. Med. Scand., 1935, Ixxxiv, 550; Journ. Amer. Med
Assoc., 1936, cvi, 1968.
Zondek, H., and G. Koehler. Med. Klinik, 1932, xxviii, 1125
.
489
on
An Operation for the Cure of Congenital Absence
of the Vagina
BY
A. H. McINDoE, M.B., Ch.B. (N.Z.), M.Sc., M.S.,
F.R.C.S. (Eng.), F.A.C.S.
AND
J. BRIGHT BANISTERT
M.A., M.D., B.Ch. (Cantab.), F.R.C.P. (Lond.), F.R.C.S. (Ed.).
Late Senior Obstetric Surgeon to Charing Cross Hospital and
Chelsea Hospital for Women.
THE treatment of congenital absence of the vagina appears to
have exercised the patience and skill of gynaecologists for many
years. A glance at the literature shows that there is no settled
opinion as to the correct management of the condition, while
there are some definitely opposed to its surgical treatment by any
existing method. Three procedures have been used by those who
are surgically inclined :
(a) Free grafts. Heppner,’ Abbe,” Flynn,’ Kirschner and
Wagner,*'* Monod and Iselin.*
Here free skin grafts, usually in multiple small pieces, are
applied to the walls of the cavity made between the rectum and
the bladder and maintained there by some form of flexible or
rigid mould for 7 to 10 days. At the end of that time the mould
is removed and the calibre of the cavity maintained as far as
possible by intermittent dilatation. In the words of Monod and
Iselin this must be begun early, repeated frequently and pro-
longed indefinitely. Judging from reported cases the results are
indifferent and appear to run parallel with the efficacy of the
subsequent dilatation.
(b) Pediculated flaps. Graves‘ first advocated the use of two
full thickness pediculated flaps turned up from the thighs and in-
serted into a pre-formed vaginal cavity. Frank and Geist’ modi-
fied this as an application of the Gillies tubed pedicle with better
results. They stated that the only methods which can compare
with it are the Baldwin,* Mori,’ and Schubert*® operations,
+ Died April 16th, 1938,
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CONGENITAL ABSENCE OF THE VAGINA
Though we have not used Graves’s method, considerable experi-
ence with tubed pedicles elsewhere in the body leaves no doubt
that it is not easy, is liable to complications, and will produce
considerable scarring of the thighs.
(c) Intestinal transplantation. The most important of these
are the Baldwin and Mori operations in which a loop of small
intestine is utilized for the formation of a new vagina, and the
Schubert procedure, which involves transplantation of the rectum
forwards, the sigmoid being brought down to take its place.
Unquestionably the former has held the field ever since its intro-
duction, despite its indefensible mortality of 10 to 20 per cent,
difficulty of performance, and the fact that if successful the
patient is supplied with a piece of gut as an organ of coitus.
There is no doubt that neither of these formidable operations
would ever have become popular if the simpler method of free
skin grafting had not been unsatisfactory. That this is so is
indicated by the records of partial or complete contraction occur-
ring in a high percentage of the reported cases. Comparison of
the methods used with those adopted in the successful perform-
ance of cavity grafts elsewhere in the body (McIndoe’’) convinced
one of us long ago that what is wrong is not so much the principle
of the method but the manner of its performance. It is one thing
to line a subcutaneous cavity with thin skin, but an entirely dif-
ferent matter to maintain the patency of the cavity once the grafts
have taken. It is well known that if left to itself free grafted
skin uniformly undergoes a contractile phase less marked on
convex surfaces where there is circumferential tension, and most
marked when this circumferential tension is poor or absent, such
as on concave surfaces or in body cavities. This contractile phase
lasts from 3 to 6 months, after which time absorption is complete
and contraction ceases. If the graft is prevented from shrinking
by a continuous stretching force throughout the entire period of
contraction it does not occur at all. As a means of preventing
contraction intermittent dilatation is a quite inadequate measure
and it is for this reason that vaginal free grafts have not been
so satisfactory as they should have been.
Applying, then, the same principles which govern the treat-
ment of the syphilitic nose (Gillies’’), the obliterated buccal sulcus,
the obliterated eye-socket (Esser,’* Gillies) the external audi-
tory meatus (McIndoe"), and in hypospadias the absent urethra
(McIndoe"*), the operation for the cure of congenital absence of
the vagina becomes a relatively simple one. It is well within the
scope of any surgeon who can cut an adequately thin skin graft,
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
It does not endanger the life of the patient or produce any
secondary deformity, and should give a uniformly satisfactory
result. In 1936 the plan and details of the proposed treatment
had been suggested (by McIndoe) to V. S. Counseller, of the
Mayo Clinic, who in a private communication has since reported
the successful treatment of five cases. The opportunity of putting
these principles into effect in England, however, was not given
until Mr. Chapman, of Grimsby, referred Miss C. to one of us
(Banister) for gynaecological opinion and treatment. Throughout
the case close gynaecological and plastic co-operation has been
maintained. Our experience of this and subsequent cases would
indicate that for congenital absence of the vagina the procedure
is so simple and safe that any abdominal operation is now out
of the question. (Fig. 1.) .
CASE REPORT.
The patient, aged 22 years, had never menstruated and men-
strual molimena of any kind were absent. Upon routine examina-
tion Mr. Chapman found the vagina absent and did not advise
any treatment. Later the question of nubility arose and the
patient was admitted to the Chelsea Hospital for Women. Ex-
amination under an anaesthetic revealed complete absence of the
vagina but a fairly well-formed vulva. On rectal examination a
small knob was felt in the position of the uterus but no trace of
ovaries. The secondary characteristics were entirely feminine. It
was decided to operate, and this was carried out in the following
way on September 27th, 1937.
A hollow vulcanite mould completely closed at both ends had
been previously prepared by our dental colleague, Mr. Alexander
Kay, roughly the size and shape of a distended virgin vagina
(Fig. 2). This was intended to carry the skin graft and to main-
tain the patency of the vagina during the entire contractile phase.
A thin razor graft was first cut from the inner surface of the
left thigh where hair was least apparent. This graft was
roughly 93 inches long by 23 inches broad. The patient was then
placed in the lithotomy position and thorough sterilization of the
vulva carried out, care being taken to see that the anus was ex-
cluded from the operative field. An incision was then made from
a point 4 inch posterior to the urethral meatus and carried verti-
cally backwards to a point # inch in front of the anus. The
plane of cleavage between the rectum and the bladder was then
entered and by blunt dissection a cavity established which was
492
3
i! |
& Nee a
:
6
}
Fic. 2.
HOLLOW VULCANITE MOULD USED TO CARRY THE
SKIN GRAFT.
hed =|
FIG. 3.
SKIN-GRAFTED VAGINA CONTAINING FULL-SIZED
GLAss VAGINAL REST FIVE MONTHS AFTER
OPERATION.
|
a
| F
gy
;
\
Fic. 4.
APPEARANCE OF THE NEW VAGINA AFTER REMOVAL
OF THE REST,
:
4 Dd
=
=
CONGENITAL ABSENCE OF THE VAGINA
gradually enlarged upwards until it would just accommodate
under moderate tension the vulcanite mould previously prepared.
Bleeding proved to be almost negligible, and a dry field was
easily obtained. The mould was then painted with mastisol and
covered with the skin graft, raw surface outwards, in such a way
that the combination of adhesive and the lie of the graft prevented
the skin rucking off during insertion. The skin-covered mould
was finally inserted into the cavity and the labia minora freshened
and sutured across its lower end leaving a small hole anteriorly
just behind the meatus for drainage.
For 72 hours after the operation the patient required a fair
amount of sedative. There was a profuse discharge for the first
Io days after which it gradually diminished in amount, and in
4 weeks had almost disappeared. The perineal wound healed
rapidly, all stitches being removed on the tenth day. The bowels
were not opened until the eighth day. The temperature rose to
1o1°F. on occasions during the first 7 days, but became normal
on the fourteenth day. She was up on the nineteenth day. After
the fourteenth day she noticed that there was some movement of
the obturator on turning in bed. She was discharged on the
twenty-sixth day to her home in Yorkshire, where Dr. Clarke,
of Rotherham, has been in charge of the case. On December rath,
1937, he reported her condition as follows:
Getting about is difficult owing to an aching pain which comes on
after exertion, but she can sit with comfort on an air ring tor 2 to 3
hours at a time. She has no difficulty with bowels or bladder. She
feels that the obturator is moving both backwards and torwards, and
she thinks there is some rotation. There is a thin yellow discharge which
is odourless and not irritating.
On January 13th, 1938, the patient returned to the Chelsea
Hospital for Women, and the vaginal mould was removed. The
skin graft had taken perfectly everywhere except for a small area
at the lower end where it lay in contact with the labia minora.
The walls were smooth, white, and soft, and approximated very
closely to normal vaginal mucosa. A glass vaginal rest of the
largest size was easily inserted into the cavity, and this was worn
every night for a further 6 weeks (Fig. 3). For a short time half-
strength eusol douches were given daily to disinfect the lower
segment where a slight irritation was evident. At the end of 5
months the new vagina was completely healed and did not show
any tendency to contraction either in length or breadth. The
introitus now admits two fingers with ease and the dimensions
of the new vagina are 5 inches by 2 inches (Fig. 4).
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
COMMENT.
The operation described has now been carried out in three
cases, two of which are still in the intermediate stage. Certain
modifications have been made in the technique particularly in
regard to the size of the obturator, which in the reported case
was somewhat large. The patient was not as comfortable during
the post-operative period as she might have been. Essentially
the principles remain the same. The method, briefly, entails the
use of a one-piece razor graft on a smooth vulcanite mould which
is buried under tension in the new vaginal cavity so that the graft
lies in intimate contact with the surrounding tissues. During the
whole period of the contraction, common to all free skin grafts,
the mould remains in situ and it is not removed until shrinkage
can no longer occur. As this is a variable period it is recom-
mended that the mould should be left alone for 6 months and
that glass vaginal rests be used nightly until such time as the
introitus is soundly healed.
REFERENCES.
1. Heppner. (1872) Cited by Paunz, Zentralb. f. Gynikol., 1923, xlvii, 883.
2. Abbé, R. Medical Record New York, 1808, lxiv, 836.
3. Flynn, C. W., and J. W. Duckett. Surg. Gynecol. and Obstet., 1936,
Ixii, 753.
4. Kirschner, M., and G. A. Wagner. Zentralb. f. Gyniikol., 1930, liv,
2960.
5. Monod and Iselin. Mem. l’Acad. de Chir. Par., 1936, Ixii, 997.
6. Graves, W. P. ‘‘Textbook of Gynecology,’’ Philadelphia, 1916.
7. Frank, R. T., and S, H. Geist. Amer. Journ. Obstet. and Gynecol.,
1927, XiV, 712}; 1932, xxiii, 256.
8. Baldwin, A. F. Ann. Surg., 1904, xl, 398; Amer. Journ. Obstet. and
Gynecol., 1907, lvi, 636.
9. Mori, M. Zentralb. f. Gynikol., 1909, xxxili, 172; 1910, xxxiv, ITI.
10. Schubert, G. Surg. Gynecol. and Obstet., 1914, xix, 376.
11. McIndoe, A. H. Surgery, 1937, i, 535.
12. Gillies, H. D. Brit. Med. Journ., 1923, ii, 977; Brit. Dent. Journ., 1935,
lix, +367.
13. Esser, J. F. Ann. Surg., 1917, Ixv, 307.
14. Gillies, H. D., and T. P. Kilner. Lancet, 1932, ccxxiii, 13609.
15. McIndoe, A. H. Amer. Journ. Surg., 1937, xxxviii, 176.
16. Wagner. Arch. f. Gynikol., 1923, cxx, 136.
494
Treatment of Puerperal Sepsis by Prontosil and
Allied Compounds
BY
Doris B. Brown, B.Sc., M.D. (Leeds), Ch.B., F.R.C.S. (Eng.)
Obstetric Tutor, Queen’s University, Belfast.
THIS paper deals with 39 cases of puerperal sepsis due to the
haemolytic streptococcus (Group A of Lancefield') treated in the
Royal Maternity Hospital, Belfast, between May 1936 and
December 1937, all of which have been under my personal super-
vision.
The cases are entirely unselected and every case which was
proved bacteriologically to be due to an infection by the Group A
haemolytic streptococcus has been included with the exception of
the following two cases. One of these had a few colonies of
haemolytic streptococci in the uterus in addition to a massive
infection with bacillus Welchii and she died of a generalized gas
gangrene; the other had a local infection of the uterus accom-
panied by almost complete suppression of urine on admission
and died of uraemia 3 days later.
In addition the results of treatment of 35 cases of mastitis and
8 cases of bacillus coli infection of the urinary tract by prontosil
are described.
Of the 39 patients suffering from puerperal sepsis there were
27 with local infection of the uterus, 8 with septicaemia, two of
whom also had general peritonitis, and 4 cases of general
peritonitis alone.
Prontosil was administered intramuscularly and by mouth.
Prontosil Soluble was used in all the cases of puerperal sepsis but
in 4 mild cases the dosage was not more than I gramme. In the
first 5 cases treated the first dose was given intravenously but in
the remainder of the cases only by intramuscular injection. It
was given in the dosage of 20 c.c. (0.5 gramme) two or three times
daily, the amount being decreased as the patient improved. Red
prontosil was given orally in the first 6 cases but was replaced by
prontosil album. The dosage was 1.8 to 6 grammes daily with an
average of 4 to 5 grammes. As we gained experience in the use of
the drug and found very few toxic effects we gave increasingly
495
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
larger doses. After reading the paper by Foulis and Barr’ on the
treatment of puerperal sepsis by large doses of prontosil album
alone we gave as many as 36 tablets (10.8 grammes) daily but
we found that the patients had difficulty in taking this number
and preferred the discomfort of intramuscular injections.
For a short time prontosil album was replaced by prosep-
tasine (May and Baker) and recently by sulphonamide-P
(Burroughs Wellcome and Co.).
Local Infection of the Uterus.
Of the 27 cases in which infection was limited to the birth
canal, 14 were of mild or moderate severity and would almost
certainly have recovered without prontosil. Certain features of
these cases are interesting. .
None of this first group of cases developed pyrexia within
48 hours of delivery, and only two did so before the 3rd day of
the puerperium. Prontosil was administered on the day ot
onset of fever in 4 cases, on the 2nd day in 6, on the 3rd day in 3,
and on the 4th day in the remaining case. It is possible that the
early treatment had some connexion with the mild nature of the
disease.
In addition to haemolytic streptococci in the uterus 2 patients
had a bacillus coli infection of the uterus and also of the urinary
tract and one patient also had a bacillus coli septicaemia. Two
others had a bacillus coli pyelitis.
The average dose was 35 grammes of prontosil over 11.6 days.
Thirteen of the patients with local infection of the uterus due
to the haemolytic streptococci were seriously ill. On admission
the temperature averaged 103°F. and only in one case was the
pulse-rate below 125 and in most cases it was between 130 and
140. Two cases probably had general peritonitis, but they have
not been classed with the cases of peritonitis as the abdominal
condition improved so rapidly after treatment with prontosil
that we doubted the diagnosis. In both of these cases the patient
complained of abdominal pain and the abdomen was markedly
distended and tender, but rigidity and evidence of free fluid were
absent.
There was marked improvement in 11 of these patients after
the administration of prontosil; in one patient it had no effect
and in one death occurred from agranulocytosis after the sepsis
had apparently been controlled.
In the 11 successfully treated cases the average dosage was
42.6 grammes.
496
i i
TREATMENT OF PUERPERAL SEPSIS
Of these cases 2 responded dramatically to prontosil. On
admission the outlook for both patients appeared hopeless but
after treatment for 48 hours their condition did not give any
cause for anxiety. On admission both patients had a temperature
of 103°F. and a pulse-rate of 140 and one was definitely cyanosed.
Two of the patients who responded well to prontosil had a relapse
later.
One patient with severe local infection did not respond to
treatment. She was admitted on the 11th day of the puerperium
after a difficult delivery by the forceps. Swabs from the uterus
gave a growth of Group A haemolytic streptococci and bacilli
coli. The blood-culture, which was repeated three times, gave a
negative result on each occasion. This patient was treated with
prontosil for 33 days with a total dosage of 56.6 grammes. She
had recurrent attacks of pyrexia which were not apparently
affected by prontosil, but she did not complain, never looked ill,
and she ate and slept well. The uterine swabs were repeated on
-two occasions, the second gave a growth of an atypical strep-
tococcus, and the third yielded streptococcus viridans. The
patient also had a bacillus coli pyelitis. On the 77th day she left
the hospital against advice, but her doctor reported 2 months
later that she had been perfectly well after returning home.
Cases of Septicaemia.
There were 8 cases of proved septicaemia. Of these 6 re-
covered—a mortality of 25 per cent.
One of the patients who died was the first in the hospital
to be treated with prontosil, and the dosage was inadequate.
Also 4 days elapsed between the onset of the pyrexia and
the administration of the drug. The patient was admitted in
a grave condition 2 days after a spontaneous delivery, and she ,
had obvious general peritonitis. The temperature was 102.8°F.
and the pulse-rate 132. The abdomen was distended, with
marked generalized tenderness and resistance. Group A haemo-
lytic streptococci were recovered from the blood and uterus. The
general condition deteriorated until the 4th day, when the tem-
perature rose to 103°—104°F. and the pulse-rate to 145. Prontosil
was administered for 4 days but was then discontinued because
red cells appeared in the urine. As the patient had previously
had a nephrectomy for a tuberculous kidney we considered it
unsafe to continue the drug. Within 24 hours of the administra-
tion of prontosil the temperature and pulse-rate both fell and
continued to do so as long as this was given. On discontinuing
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
the drug the general condition deteriorated and although red
prontosil tablets were given for a further 24 hours she died on
the 15th day of the puerperium. Before death there was massive
oedema of the lower limbs and a generalized petechial rash. The
blood-culture, which was positive on three different occasions,
became negative on the 5th day after the administration of pron-
tosil. At autopsy the peritoneal cavity was found to contain a
large quantity of thin turbid fluid. It is interesting to note that
the endocardium and lining of the aorta were stained a deep
rose-red colour. The total dose in this case was only 14 grammes.
Ii this had occurred later in our series we should almost certainly
have given a much larger amount over a longer. period.
The second fatal case was admitted 4 days after a manual
removal of the placenta. The patient had had a rigor before
delivery. On admission she was cyanosed, had a temperatutre
of 103°F., and her heart was fibrillating. The uterus was pro-
lapsed. Blood-culture yielded haemolytic streptococci on two
occasions, and haemolytic streptococci, bacillus coli, and staphy-
lococci were recovered from the uterus. There was never any
improvement in her condition. She was given 21.6 grammes of
prontosil.
Three of our patients suffering from septicaemia made
dramatic recoveries. One was a case of prolonged first stage due
to uterine inertia. Twenty-four hours before delivery she
developed a temperature of 102°F. and haemolytic streptococci
were then recovered from the blood. She was delivered spon-
taneously of a stillborn child after 104 hours of labour, and a
few hours later her temperature rose to 105°F. Prontosil was
administered after delivery and her temperature fell to normal
on the 3rd day and remained low. She developed acute mania
and was transferred to a mental hospital on the rath day of
the puerperium. The blood was then sterile. Two months later
an abscess was incised above the right inguinal ligament. She
made a complete recovery. The total dosage given was I9
grammes of prontosil over a period of g days.
The next case was in the labour ward at the same time as the
case just described. Within 12 hours of a normal delivery she
had a temperature of 105°F. and haemolytic streptococci were
recovered from her blood. She made a remarkable recovery, and
the temperature became normal in 3 days and remained low.
On the roth day she developed a mild thrombosis of the left
external saphenous vein but this resolved very rapidly. The
patient was a small, frail-looking woman, but she never looked
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TREATMENT OF PUERPERAL SEPSIS
really ill. In all 20.1 grammes of prontosil were given. Within a
few months of leaving hospital she again became pregnant and
has recently been delivered. There was no rise of temperature
during the puerperium. She was given I gramme of prontosil
soluble as a prophylactic.
The third patient had a rigor 5 days after delivery and the tem-
perature rose to 105°F. She became semi-comatose and delirious.
Prontosil soluble and sulphonamide-P were given immediately
and the temperature fell to between 99°F. and 100°F. in 3 days
and after several days became normal. The blood, which at the
onset gave a very heavy growth of haemolytic streptococci,
became sterile in 2 days. She was discharged well on the 27th
day. She was given a total dose of 49 grammes.
The other patients suffering from septicaemia were given
much larger doses of prontosil, namely 189.4, 66.3, and 186.5
grammes over a period of 38, 35, and 31 days respectively.
One patient was admitted 5 days after a difficult delivery by
the forceps and manual removal of the placenta. The tempera-
ture had probably been raised from the 2nd day of the puer-
perium. She was severely ill on admission, and the temperature
rapidly rose to 103 °F. and the pulse-rate to 140. She was anaemic
with a haemoglobin of 40 per cent. Prontosil was given and the
temperature and pulse-rate gradually fell to almost normal in the
first week. Intramuscular prontosil was stopped in 10 days, but
the tablets were continued. However, the temperature rose to
102°F. on the 17th day and she became as ill as before the admini-
stration of prontosil. The blood was now sterile. With further
treatment by large doses of prontosil soluble and prontosil
album the condition improved and she was discharged well on
the 35th day.
The next patient was very ill when admitted 3 days after a
normal delivery. The temperature was 101.6°F. and the pulse-
rate 152. She complained of abdominal pain and marked
abdominal rigidity and some distension were present. The
tongue was dry and brown. Prontosil was given and although
the signs of peritonitis had disappeared in a week and the patient
looked and felt bettetr she had an irregular temperature for 5
weeks. In the 3rd week of the puerperium she developed a
swollen left leg with marked tenderness over the calf. This sub-
sided but a month later she had a further slight rise of tempera-
ture and a small abscess developed in the left popliteal fossa;
this was incised. She was discharged after 60 days in hospital
with a pulse-rate between 90 and 100. When seen one month later
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she was perfectly well. The blood culture was sterile on the
4th day after treatment but became positive on the 7th day and
then remained sterile.
The last patient developed a temperature of 101.6°F. and a
pulse-rate of 160 on the day after a difficult delivery by the
forceps following an induction by stomach-tube for pre-eclamptic
toxaemia. She looked very ill and the tongue was dry. There
was incontinence of faeces. The abdomen was tender and rigid
in the lower part but moved well with respiration. Haemolytic
streptococci were recovered from the blood and bacilli coli and
haemolytic streptococci from the uterus. The blood became
sterile after treatment for 3 days. Prontosil was administered on
the 3rd day and although all the abdominal signs very rapidly
disappeared the general condition remained serious for 10 days
when she began to improve slowly. In the 3rd week a mild
white leg developed but this rapidly subsided. She was dis-
charged well on the 38th day.
Cases of General Peritonitis not Associated with a Septicaemia.
There were 4 cases in this class.
One patient was admitted 3 days after a normal delivery. She
had had a rigor on the day of delivery and was very ill on admis-
sion. She complained of abdominal pain, diarrhoea and vomiting.
The abdomen was tender and rigid and the temperature was
104.8°F. and the pulse-rate 140. Prontosil was given and the
temperature fell to normal on the 4th day but rose again to
104°F. on the 6th day and then gradually subsided for a week.
There was a mild recurrence of pyrexia 12 days later but this
was probably due to bacillus coli pyelitis.
The next case is interesting. On admission, 4 days after
delivery, there was marked distension and tenderness of the
abdomen with signs of free fluid. Rigidity was absent. The tem-
perature was 103°F. The patient complained of vomiting and
diarrhoea. There had been several rigors before admission.
Here the condition, which was extremely grave, improved in 4
days but after remaining well for 2 weeks she suddenly became
very ill again with all the signs and symptoms of general perito-
nitis. Prontosil had been discontinued before the relapse. The
patient improved again when the drug was re-administered.
Peritonitis occurred in another patient following a miscarriage
which was due to severe pyelitis. There were distension and
rigidity of the abdomen and marked diarrhoea. The temperature
remained irregular for 12 days after prontosil was given, then
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TREATMENT OF PUERPERAL SEPSIS
became normal for 6 days but again rose for a further 10 days.
She was not very ill during the relapse. The abdomen remained
distended, tender and rigid for one week.
The fourth patient was admitted 3 days after a normal
delivery with a temperature of 103° F. She complained of nausea
and of very severe abdominal pain. The abdomen was distended
and rigid and there was generalized tenderness which was par-
ticularly well marked in the right iliac fossa. She responded
rapidly to treatment and was discharged well on the 2oth day.
She was given 49 grammes of sulphanilamide.
Prontosil in the Treatment of Mastitis.
Thirty-five cases of mastitis have been treated by the adminis-
tration of prontosil album, proseptasine or sulphonamide-P in
the dosage of 2-3 grammes daily. The average duration of treat-
ment was 5 days.
All were severe cases and a few of the patients were very ill.
The results have been remarkable and unexpected. All these
cases resolved completely and patients suffering from mastitis
developing in the hospital between May 1936 and December 1937
have not had any breast abscesses, i.e. since prontosil was used
for acute mastitis.
We have also used sulphanilamide in a number of patients
admitted for breast abscess and although most of these cases have
required incision they have all appeared to heal up more rapidly
than usual.
Prontosil in B. col Pyelitis.
After reading the paper by Meave Kenny and others* on the
results of prontosil in bacillus coli infections of the urinary tract
we tried it in 8 cases of bacillus coli infection.
Two grammes sulphanilamide were given daily for 4, 5 or 6
days. The urine became sterile in all cases but in three patients
bacillus coli reappeared within 2 days to 4 weeks. All these three
patients were undelivered.
Toxic Effects.
Four of the patients with puerperal sepsis who were treated
by prontosil developed cyanosis—one markedly and_ three
slightly. Two of these had been given magnesium sulphate.
Seven of the 35 patients suffering from mastitis became
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cyanosed, i.e. 20 per cent. In 6 cases the cyanosis was slight,
the patients were not ill and the pulse-rate did not rise. The
other patient looked extremely ill and had a pulse-rate of 120,
but she stated that she felt well. Her haemoglobin was 68 per
cent. The cyanosis gradually disappeared when prontosil was
stopped. The administration of prontosil was continued so long
as it was considered necessary in the other cases in spite of th
cyanosis.
Samples of blood were not examined in all cases for sul-
phaemoglobin but this was found in all cases which were investi-
gated. The blood was not examined unless cyanosis was present.
From this it appears that the dosage has little to do with the
development of cyanosis; it did not appear in those patients who
had been given massive doses. Most cases occurred in the
patients with mastitis, probably because they were more liable to
be given magnesium sulphate and also because these patients
were less anaemic than those suffering from puerperal sepsis due
to haemolytic streptococci and so the cyanosis was more
obvious. Possibly some of the sulphur was derived from the
food as they were on a normal diet consisting of a fairly large
amount of protein. We have also noticed repeatedly that the
cyanosis has been most severe in cases of sepsis due to organisms
other than the haemolytic streptococcus.
Prontosil was not stopped when cyanosis appeared except .in
the one patient suffering from mastitis in whom the pulse-rate
rose. Discombe* states that the drug should be stopped at the
onset of cyanosis. It would probably be better to discontinue
prontosil in any case of mastitis if cyanosis occurs, as the worst
thing that can happen in these cases is the development of a
breast abscess, but in a case of severe sepsis it is wiser to continue
the administration in spite of the presence of sulphaemoglobin or
methaemoglobin unless the pulse-rate is rising. However, most
cases of sulphaemoglobinaemia can be avoided by prohibiting
sulphates.
A small number of our cases developed albuminuria after
prontosil and a very few had red cells in the urine. The urine was
not examined microscopically in every case. Albuminuria
seemed to be relatively more common in cases of pyelitis.
Prontosil is said to be less rapidly excreted in cases of renal
damage,’ therefore it is an important point to determine whether
it should be given in cases of impaired renal function. We have
used it in 6 cases of pre-eclamptic toxaemia and in I case of severe
accidental haemorrhage in a toxaemic patient. None of these
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TREATMENT OF PUERPERAL SEPSIS
patients appeared to be harmed by the drug and in one patient,
who was severely infected, pregnancy, which was complicated
by severe pre-eclampsia, was terminated by the stomach tube.
She later developed septicaemia and received 186.5 grammes of
prontosil. It is interesting to note that in all but one of these cases
the albumin disappeared from the urine while the patients were
being treated with prontosil. In one patient the blood-urea was
2I mgm. per cent and the urea clearance 104 per cent after the
administration of 56.6 grammes of prontosil.
Two patients showed a generalized scarlatiniform rash which
rapidly faded. In one case the prontosil was stopped when the |
rash appeared but it was continued in the other.
_ Two patients showed great prostration and severe headache
but recovered rapidly after the cessation of the drug.
In two of the cases of severe sepsis, jaundice appeared on the
oth and 17th days of the puerperium after 23 and 33.5 grammes
of sulphanilamide, respectively, had been given. Although it is
not possible to be sure whether the jaundice was due to the sepsis
or to the prontosil it is very probable that it was due to the latter
since the sepsis was under control before the jaundice appeared
and after prontosil was discontinued the jaundice rapidly faded.
One case of agranulocytosis associated with the administration
of prontosil occurred. This complication is rare but cases have
been reported by Borst,° Young,’ and Model.* The results are so
serious that a full description of this case is merited.
The patient was a primipara aged 22, with mild pre-eclamptic
toxaemia, who developed a temperature of 103°F. on the second
evening after the breech delivery of a stillborn infant; her
perineum was completely torn. The uterine swab gave a growth
of haemolytic streptococci but the blood was sterile. Prontosil
soluble and sulphonamide-P were immediately given and the
temperature fell by lysis until it reached 99°F. on the 11th day
of the puerperium. The drug was then discontinued but was
given again on the 14th day as the temperature had risen to
z102°F. The temperature fell in 48 hours but prontosil was con-
tinued in decreasing dosage until the 19th day. She appeared
well until the 24th day when the temperature rose to 104°F.
Prontosil was again given but was discontinued in 24 hours as
the white-cell count was only 1,500. Glossitis was not present.
The blood was again sterile. The next day the leucocyte count
had fallen to 450 with very few polymorphonuclear leucocytes.
The urine was almost solid with albumin. A red inflamed area
appeared round the complete tear which had not healed.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
The temperature remained hectic (between 104° and 105°F.)
and she died on the 30th day of the puerperium in spite of
treatment with concentrated liver extract. She never complained
of anything except tiredness and on the day of her death she
developed small ulcers in the vagina and an urticarial rash on her
knuckles. Aphonia and dysphagia developed a few hours before
death. A blood-culture taken at this time gave a profuse growth
of haemolytic streptococcus and haemolytic staphlylococcus
aureus. The total dosage of prontosil and sulphonamide-P was
78.5 grammes given over a period of 17 days.
Unfortunately a post-mortem was not allowed. Although it
cannot be said with absolute certainty that the agranulocytosis
was due to the prontosil it is very probable that it was. Agranulo-
cytosis has been described associated with sepsis alone but in this
case the patient had almost recovered from the sepsis before the
agranulocytosis developed. The terminal blood infection was
due to the loss of resistance due to the disappearance of the poly-
morphonuclear leucocytes.
Discussion.
From the above data it seems that prontosil is of definite value
in the treatment of puerperal sepsis due to the haemolytic strep-
tococcus.
From September 1933 to April 1936 in the Royal Maternity
Hospital, Belfast, there were 18 cases of local infection of the
uterus by the haemolytic streptococcus. Of these, one patient
died, giving a mortality of 5.55 per cent. From May 1936 to
December 1937 there have been 27 cases with one death which
was due to agranulocytosis.
There were 4 cases of pelvic cellulitis before May 1936. There
were no deaths, but the average stay in hospital was 65 days.
Since the use of prontosil a case of pelvic cellulitis has not
occurred.
There were 8 cases of septicaemia before prontosil was used.
Only one patient recovered and she was never very ill and her
temperature did not rise before the 8th day. This gives a death-
rate of 87.5 per cent for septicaemia and a mortality of 23.53 per
cent for all cases of infection by the haemolytic streptococcus
before the administration of prontosil. Since then there have
been 8 cases of septicaemia with 6 recoveries, a mortality of 25
per cent, and the death-rate for all cases of puerperal sepsis due
to the haemolytic streptococcus is 7.7 per cent. The following
table makes these figures clear.
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TREATMENT OF PUERPERAL SEPSIS
Mortality of infections due to the haemolytic streptococcus.
Before prontosil After prontosil
Per cent Per cent
Local infection ...... 5-55
General infection 28 87.5 25
Also one death was probably due to a combination of in-
adequate dosage and late administration. Prontosil probably was
of benefit in this case and it almost certainly prolonged life, for
although this was a case of general peritonitis and septicaemia
starting on the 1st day of the puerperium the patient lived for
15 days. After 4 days’ treatment with prontosil the blood-culture
became negative, and it is possible that this patient might have
recovered had we not so soon discontinued the drug.
The second patient who died had a mixed infection of the
uterus in addition to the streptococcal blood infection, and she
was not given prontosil until 4 days after the onset of the pyrexia.
In this case and also in one case of local infection prontosil seemed
to have no influence on the progress of the disease. In both these
cases other organisms in addition to the haemolytic streptococcus
were present in the uterus.
It is interesting that although one case of local infection was
not benefited by prontosil and on admission had Group A haemo-
lytic streptococci in the uterus, after treatment by prontosil the
uterine swabs gave a growth of an atypical streptococcus and a
still later swab yielded a growth of streptococcus viridans. ~
None of our patients with general peritonitis due to the haemo-
lytic streptococcus recovered before prontosil was used. Since
May 19360 there have been 6 cases and probably 2 others in
addition. All these patients recovered except one who had
septicaemia, which has already been described. Although
laparotomy was not performed in any case and in only one was
the diagnosis confirmed at autopsy the patients had all the signs
and symptoms of general peritonitis, and these patients were seen
by members of the visiting staff who have been observing cases
of puerperal peritonitis for many years. Also if these patients
had not peritonitis the only other alternative is that peritonitis
no longer occurs in this hospital.
In addition to prontosil, most of the patients suffering from
severe puerperal sepsis, especially those with general peritonitis,
were given a continuous-drip saline transfusion, and those with
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
a severe degree of anaemia were given one or more small blood
transfusions.
Although the mortality of cases of puerperal sepsis due to
the haemolytic streptococcus has been greatly decreased by
prontosil our results have not been so dramatic as those reported
by Colebrook and Kenny.’ In most of their cases the temperature
fell to normal in 24 to 72 hours and remained normal. In only
12 of our 36 patients who responded to treatment did the tem-
perature fall to normal within 3 days, and thereafter remain
normal. In 14 cases the temperature gradually fell over a period
of I, 2, or 3 weeks and in the other ro cases there was a relapse.
These latter cases are interesting. In 5 of them the recrudescence
of signs and symptoms occurred after both forms of prontosil had
been stopped for 12, 11, and 3 days respectively. Two patients
became worse after prontosil soluble had been discontinued but
while they were still having prontosil album. All these patients
responded to re-administration of full doses of prontosil. The
other three patients relapsed in spite of the administration of
both oral and intramuscular prontosil.
These relapses suggest that the infection is merely damped
down by prontosil, which may possibly either diminish the
virulence of the haemolytic streptococci or hinder their mul-
tiplication. This is in keeping with the growth curves of haemo-
lytic streptococci in horse-serum and in serum-sulphanilamide
obtained by Long and Bliss.”°
The time spent in hospital has not been much diminished
since prontosil has been used. Excluding cases kept in for reasons
other than sepsis, the duration of stay in hospital for cases of
local infection was 22 days before and 19 days after prontosil
was used. However, there have not been any cases of pelvic
cellulitis since the introduction of the drug, and the average time
in hospital for these patients was 65 days.
The fact that the duration of stay in hospital has not markedly
decreased since prontosil was used seems to indicate that the
virulence of the haemolytic streptococcus has not decreased
recently, which is the alternative explanation given by Gibberd”’
for the good results obtained in generalized infections due to this
organism.
No patient in the series, while under treatment with prontosil,
developed a palpable pelvic or pelvi-abdominal inflammatory
mass. This is in agreement with the results obtained by Cole-
brook and Kenny.* However, one patient who was transferred
to a mental hospital for puerperal mania developed an abscess in
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TREATMENT OF PUERPERAL SEPSIS
the groin 2 months later. It is possible that prontosil, which
was given for g days in this case, was discontinued too soon.
We have used prontosil prophylactically in a considerable
number of patients who have either been in contact with persons
infected with the haemolytic streptococci or have been subjected
to manipulative interference. None of these patients have
developed puerperal sepsis due to the haemolytic streptococcus,
but it is impossible to tell whether or not they would have done
so if prontosil had not been given. In December 1937 the prophy-
lactic use of prontosil was tried on a large scale. Two cases of
infection by the haemolytic streptococcus occurred in different
units of the hospital. Every patient in the hospital received 1
gramme of sulphonamide-P four times daily for 2 days and no
other case of sepsis developed. The experimental evidence is all
in favour of the use of prontosil as a prophylactic. Levaditi and
Vaisman, quoted by Colebrook and Kenny,” have claimed that
by subcutaneous administration of a large dose (50 mgm.) of
prontosil in suspension, mice are frequently protected against
fatal doses of streptococcal culture injected 5 to 10 days later.
Very large doses of prontosil have been given, especially in the
later cases in our stages. In 2 patients with septicaemia the dosage
was 189.4 and 186.5 grammes over a period of 36 and 31 days
respectively. This is a much larger amount than that recom-
mended by Colebrook and Kenny.’ These authors gave 20 cubic
centimetres of prontosil soluble 8 hourly and 12 tablets of pron-
tosil album in the 24 hours (total of 5.5 grammes) and state that
in the ‘‘gravest cases these large doses have been continued for a
week or more’’. We found that the patients did not respond so
well if smaller doses were given and they relapsed if the adminis-
tration was stopped too soon.
Two patients suffering from septicaemia responded to a much
smaller dosage, namely 19 and 20 grammes, respectively. In
both these cases prontosil was given within a few hours of the rise
in temperature, so it appears that the earlier the drug is adminis-
tered the smaller should be the dose administered. It is probable
that the early administration of the drug is the most important
factor in success or failure of the treatment. In support of this
are the experiments of Colebrook and Kenny” on mice infected
with cultures of the haemolytic streptococcus. They state that the
infection ‘‘can be checked in the majority of the animals if treat-
ment is commenced within 3 hours of the injection of culture. If
delayed much longer than that time the death of the animal may
be postponed for a day or two, but it is not usually avoided.”
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
The use of prontosil in cases of mastitis is empirical. Mastitis
is nearly always due to the staphylococcus aureus, which is said
not to be influenced by prontosil,’* although Domagh, quoted by
Colebrook and Kenny,’’ claims that prontosil has some action
upon staphylococcal infections in the rabbit. In all cases in
which the milk was examined bacteriologically from these
patients the staphylococcus aureus was recovered.
The breasts were also treated by support and antiphlogistine.
This treatment was given before May 1936, and in the year pre-
ceding the administration of prontosil out of 18 cases of mastitis
occurring in the hospital, 9, i.e. 50 per cent, resulted in the for-
mation of abscesses which needed incision. The other 9g cases
resolved.
Since a case of mastitis occurring in the hospital has not
resulted in the patient having a breast abscess since the use of
prontosil, the continued use of the drug in this condition is
justified.
I wish to thank Professor C. G. Lowry and Mr. H. L. Hardy
Greer for allowing me to use the case records of their patients.
REFERENCES.
. Lancefield, R. C. Journ. Exper. Med., 1933, lvii, 571.
. Foulis, M. A., and J. B. Barr. Brit. Med. Journ., 1937, Pp. 445.
. Kenny, Meave, and others. Lancet, July 17th, 1937, p. 119.
. Discombe, G. Lancet, 1937, p. 626.
. Marshall, E. K., K. Emerson, and W. C. Cutting. Journ. Amer, Med.
Assoc., 1937, March 2oth, p. 105.
. Borst, J. G. G. Lancet, 1937, i, 1519.
. Young, C. J. Brit. Med. Journ., 10937, ii, p. 105.
. Model, A. Brit. Med. Journ., 1937, ii, Pp. 295.
. Colebrook, L., and M. Kenny. The Lancet, 1936, ii, 1319.
. Long, Perrin H., and E. A. Bliss. Journ. Amer. Med. Assoc., 1937,
January 2nd, p. 32.
. Gibberd, G. F. Brit. Med. Journ., October 9th, 1937, p. 695.
. Colebrook, L., and M. Kenny. Lancet, 1936, i, 1279.
. Buttle, G. A. H., W. H. Gray, and D. Stephenson. Lancet, 1936, i.
1286.
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508
Induction of Labour by Puncture of the Membranes *
REVIEW OF 357 CASES.
BY
R. A. TENNENT, M.B., Ch.B. (Glas.), M.C.O.G.
Assistant Surgeon to the Gynaecological Out-Patient Depariment,
Glasgow Royal Infirmary; Late House Surgeon, Glasgow Royal
Maternity and Women’s Hospital.
DuRING the six years ending December 1936, puncture of the
membranes has been the routine method of surgical induction
of labour in Professor Hendry’s unit of the Glasgow Royal Mater-
nity and Women’s Hospital. In this period the method was used
in 357 cases. This paper is an analysis of the results in these
cases and an attempt to estimate the efficiency and safety of the
method.
In British literature Williamson’ (1905) described the method
and stated that most patients went into labour within 2 days.
The majority of labours were induced on account of dispropor-
tion and the foetal mortality was 41.7 per cent. Smythe’ (1931)
described the method and also a special catheter for use in the
operation. He found that in most cases labour began within
24 hours and that sepsis did not result from the method. Fitz-
gibbon* (1931) reported 23 cases and analysed the results. Smythe
and Thompson‘ (1937) reported 210 cases, also analysing the
results.
In American literature Jackson’ (1929) reported a series of
87 cases in which labour had been induced by a combination of
puncture of the membranes and small doses of pituitary extract.
Guttmacher and Douglas‘ (1931) reported a series of 120 cases.
In most of these labour was induced by puncture of the mem-
branes preceded by premedication with castor oil and quinine
and followed by pituitary extract. In a number of cases the
pituitary extract was omitted for purposes of comparison.
Rucker’ (1932) reported 64 cases in which the method was used
* From Professor T. Hendry’s Unit, Glasgow Royal Maternity and
Women’s Hospital.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
in conjunction with castor oil and quinine premedication. Ayo‘
(1932) reported 20 patients to whom castor oil was given before
puncture of the membranes and to whom pituitary extract was
given after. Slemons’ (1932), Morton’’ (1933), Wilson"’ (1934),
and McGoogen”’ (1935) have each published reports of series of
patients on whom induction of labour was performed by medi-
cation of castor oil and quinine, puncture of the membranes, and
finally small doses of pituitary extract. Jackson’* (1934) reported
500 cases in which puncture of the membranes was preceded by
castor oil and quinine medication.
METHOD.
The method employed was simple puncture of the membranes.
Premedication was not employed and pituitary extract was not
administered afterwards unless the latent period extended over
24 hours, in which case the method is not regarded as successful
for purposes of this paper. The membranes were punctured by
introducing an ordinary male metal catheter or a Drew-Smythe
catheter* through the cervical canal. The catheter was guided
past the presenting part and the membranes punctured by giving
the catheter a sharp turn, or in the case of the Drew-Smythe
catheter by using the stilette. The liquor was allowed to drain
through the catheter until the flow ceased, pressure being applied
to the abdomen so long as the instrument was in position. Usually
an anaesthetic was not required, the procedure not giving rise to
any discomfort. A speculum was not used and the cervix was not
caught by forceps, the catheter being directed by two fingers
introduced into the vagina. In some primigravidae in whom
the cervix was long and rigid with a narrow canal, general anaes-
thesia was necessary and the cervix was grasped with forceps to
facilitate introduction of the catheter.
LATENT PERIOD.
To record the latent period, i.e. the time from puncture of the
membranes to the onset of labour pains, and also for the recording
of the duration of labour, the cases are divided into primigravidae
and multiparae. The two groups are analysed separately as the
types of labour are not comparable. There were 100 primi-
gravidae and 257 multiparae. Each group is further subdivided
into four groups according to the duration of the gestation, but
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INDUCTION OF LABOUR BY PUNCTURE OF THE MEMBRANES
only patients who were 28 weeks pregnant and over are included
in the series.
Table I gives the results for the complete groups.
TABLE I.
100 primigravidae 257 multiparae
Duration of No. Per- No. Per-
latent period of cases centage of cases centage
o-6 hrs. 44 97 37-7
o-12 hrs. 57 131 50.9
o-24 hrs. 76 172 66.9
Over 24 hrs. 22 84 32.7
Failures 2 I 0.38
The three failures were:
1. A case of antepartum eclampsia; labour did not begin, the
pregnancy being terminated by Caesarean section.
2. A case of lateral placenta praevia; labour did not begin,
Caesarean section being performed.
3. A patient suffering from cardiac disease, which proved fatal
before the onset of labour 4 days after puncture of the mem-
branes.
Table II summarizes the results in each group according to
the duration of the pregnancy.
TABLE II.
Primigravidae Multiparae
Latent period Latent period
Duration of No. of _ less than No. of less than
pregnancy cases 24 hours % cases 24 hours Y
28-32 weeks Il 63.6 52.6
32-36 weeks 18 72.2 57-5
36-40 weeks 68 80.9 69.7
Over 40 weeks 3 33-3 73-9
From the foregoing results it appears that the method is more
efficient in primigravidae than in multiparae—76 per cent as
against 66.9 per cent. This is similar to the findings of Guttmacher
and Douglas,* Fitzgibbons,* and Smythe and Thompson,* but is
contrary to those of Jackson,’* and Ayo,* who find the latent
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
period shorter in multiparae. Guttmacher and Douglas’ compared
patients to whom pituitary extract had been given after puncture
of the membranes with patients to whom it had been left out.
They found the latent period shortened in the former.
From the results in Table II it will be seen, as might be ex-
pected, that the method is most efficient in the last four weeks of
pregnancy.
DuRATION OF LABOUR.
The duration of labour in both groups is given in Table III.
TABLE III.
1oo Primigravidae 257 Multiparae
Duration of labour No. of cases % No of cases %
Over 24 hours _... ee 9 3.5
Patients in whom labour was
terminated by Caesarean sec-
tion after trial labour st 0.38
Failures (see Table I) ... 0.38
For comparison, the duration of labour in a series of 100
normal primigravidae and 100 normal multiparae, taken at ran-
dom from the case records of the unit, has been analysed. In the
primigravidae labour lasted under 6 hours in 16, under 12 hours
in 52, and under 24 hours in 89. The corresponding figures for
the multiparae were 44, 77, and 97. These figures approximate
to the percentage figures of the induced groups. It would, there-
fore, appear that puncture of the membranes did not prolong
labour. This finding is in agreement with that of most other
writers.
MopE oF DELIVERY.
The labours of the primigravidae terminated as follows:
(a) Spontaneous delivery: 79 cases. One case had the assist-
ance of Willet’s forceps.
(b) Delivery by the forceps: 8 cases. These included 3 cases
of eclampsia; 2 patients in whom the forceps was applied to com-
plete delivery after correction of persistent occipito-posterior
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INDUCTION OF LABOUR BY PUNCTURE OF THE MEMBRANES
positions; I case of contracted pelvis; 1 case of prolapsed cord;
and 1 case of prolongation of the second stage of labour.
(c) Craniotomy: I case.
(d) Manual delivery: 8 cases. These included 4 breech pre-
sentations and 4 sets of twins.
The labours of the multiparae terminated as follows:
(a) Spontaneous delivery : 242 cases.
(b) Delivery by the forceps: 7 cases. These included 2
patients in whom the forceps was applied to complete delivery
after correction of persistent occipito-posterior positions; 2 cases
in which the foetiis were very large (11} pounds and Io pounds);
and 3 cases in which the second stage of labour was unduly pro-
longed.
(c) Manual delivery: 5 cases. These included 3 breech pre-
sentations, r set of twins, and 1 anencephalic foetus.
INDICATIONS FOR INDUCTION.
Primi- Multi-
gravidae parae
Pre-eclamptic toxaemia ae 58 88
Accidental haemorrhage 21
Partial placenta praevia 6
Chronic nephritis
Contracted pelvis
Other cases (including anencephaly;
hydramnios; pyelitis, post-maturity;
pyelitis, late vomiting; bad obstetric
4
17
6
I
4
It will be observed that, in the majority of patients the indica-
tion for induction of labour was pre-eclamptic toxaemia or
eclampsia. Stroganoff" (1934) and Blair’’ (1934) have pointed
out the advantages of puncture of the membranes in these cases.
FOETAL MORTALITY.
The total number of children in the series was 367, there being
II sets of twins and 1 patient dying undelivered. Of these 65 were
stillborn, giving a gross foetal mortality of 17.7 per cent. The
reason for such a high figure is that cases of eclampsia, pre-
eclamptic toxaemia, and accidental haemorrhage form, together,
a large proportion of the series. When the following cases in
which stillbirths occurred are deducted from the total stillbirths,
a more accurate estimate of the foetal mortality is obtained.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Pre-eclamptic toxaemia
Eclampsia
Chronic nephritis
Accidental haemorrhage
Partial placenta praevia
Hydrocephalus
Anencephaly
Intra-uterine death
Acute yellow atrophy
we
Total
By this method a corrected foetal mortality of 3.53 per cent is
obtained.
A further factor influencing the stillbirth rate is prematurity,
of which the incidence, in a series of cases in which induction of
premature labour has been employed, must be high. Of the 65
stillborn children 23 could be classed as premature, i.e. weighing
under 5 pounds. Five of these foetiis were macerated at birth.
PYREXIA AND SEPSIS.
There were 30 cases of puerperal pyrexia, i.e. when the tem-
perature rose about 100.4°F. on more than one occasion within
24 hours, giving a pyrexia-rate of 8.4 per cent. Of these the
pyrexia was due to uterine sepsis in II cases, giving a sepsis-rate
of 3.08 per cent. The other 19 cases were made up as follows:
Mastitis
Endocarditis
Endocarditis with pyelonephritis
Phthisis
Pyrexia of unknown origin
Of the 11 septic patients 5 had normal deliveries and no inter-
ference other than puncture of the membranes. Among the
other 6 patients 2 were delivered by the forceps, 1 by craniotomy,
2 manual deliveries, and 1 in which the placenta was removed
manually.
The latent periods of the 11 septic patients were as follows:
3 hours, 1? hours, 3} hours, 5 hours, 7} hours, 12 hours, 144
hours, 16; hours, 22} hours, 24 hours, 48? hours. These figures
are interesting in view of the fact that it is generally held that a
long latent period is conducive to sepsis. In this series, it will
be seen that only one of the septic patients had a latent period
lasting over 24 hours.
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INDUCTION OF LABOUR BY PUNCTURE OF THE MEMBRANES
MATERNAL MORTALITY.
There were 10 maternal deaths in the series, giving a mortality
rate of 2.8 per cent. Summaries of these cases are given below.
Case I. First para, 39 weeks pregnant, suffering from pre-eclampsia.
Latent period was 24 hours and labour lasted 2'; days. Delivery was
spontaneous. Child was stillborn and weighed 4 pounds. Patient died on
nineteenth day of the puerperium of puerperal sepsis.
CasE 2. Sixth para, 36 weeks pregnant, suffering from acute yellow
atrophy. Latent period was 1 hour. Labour lasted 1!% hours. Delivery
was spontaneous. Child was stillborn and weighed 614 pounds. Patient
died 23 hours after delivery.
CasE 3. Sixth para, 34 weeks pregnant, suffering from phthisis. Latent
period was 7434 hours. Labour lasted 3% hours. Delivery was spontaneous.
Child weighed 4 pounds and was stillborn. She was sterilized on the eleventh
day of the puerperium. She died on the twenty-sixth day of the puer-
perium. Post-mortem examination revealed pulmonary phthisis.
CasE 4. Fifth para, 37 weeks pregnant, suffering from cardiac disease.
Latent period was 2% hours. Labour lasted 214 hours. Delivery was
spontaneous. Child was alive and weighed 634 pounds. Patient died on
the eleventh day of the puerperium under anaesthesia during an operation
for sterilization.
Case 5. First para, 34 weeks pregnant, suffering from eclampsia and
mixed accidental haemorrhage. Latent period was 20% hours. Labour
lasted 8% hours. Delivery was spontaneous. Child weighed 4!; pounds
and was stillborn. Patient died on the first day of the puerperium.
CasE 6. First para, 37 weeks pregnant, suffering from cardiac disease,
with albuminuria. Patient died undelivered 4 days after puncture of
membranes. Post-mortem findings were endocarditis, pericarditis, pleurisy,
peritonitis. There was no uterine sepsis.
CasE 7. Fifth para, 32 weeks pregnant, suffering from cardiac disease.
Latent period was 17% hours. Labour lasted 17 hours. Delivery was
spontaneous. Child weighed 214 pounds and was stillborn. Patient died
on the fourth day of the puerperium. Post-mortem finding was ulcerative
endocarditis.
Case 8. Third para, 31 weeks pregnant, suffering from external acci-
dental haemorrhage. Latent period was 234 hours. Labour lasted 1 hour.
Delivery was spontaneous. Child weighed 4's pounds and was stillborn.
Patient died on the sixth day of the puerperium from cortical necrosis of
kidneys.
CasE g. Third para, 36 weeks pregnant, suffering from cardiac disease.
Latent period was 52 hours. Labour lasted 1534 hours. Delivery was
spontaneous. Child weighed 5% pounds and was alive. Patient died on
the thirteenth day of the puerperium of ulcerative endocarditis.
CasE 10. First para, at term, suffering from raised blood-pressure, con-
tracted pelvis, and acute pyelonephritis. Latent period was 3 hours.
Labour lasted 19% hours. Delivery was by the forceps after manual cor-
rection of an occipito-posterior position. Patient died on the first day of
the puerperium.
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It will be seen that, excepting Case 1, these fatalities were in
no way connected with the puncture of the membranes. In Case 1
puncture of the membranes was the only obstetrical interference,
and must, therefore, have been a factor in the origin of the sepsis.
PROLAPSE OF THE UMBILICAL CORD.
There were 3 cases of prolapse of the umbilical cord in the
series—a vertex presentation, a breech presentation, and a patient
in whom the membranes were punctured on account of haemor-
rhage following version of a breech presentation to vertex. The
first two children were stillborn, the third child was alive, being
delivered by the forceps soon after the cord prolapsed. The
danger of this accident occurring, if the presentation is abnormal
or if the vertex is high, is pointed out by Morton’® and Jackson."*
CONCLUSIONS.
1. That puncture of the membranes is a fairly reliable (i.e.
about 70 per cent) efficient method of inducing labour.
2. The labour is not prolonged or difficult after puncture of
the membranes.
3. That conclusions as regards the effect on the foetus cannot
be drawn from this series, owing to the nature of the causes for
which labour was induced.
4. That the risk of sepsis must always be considered, since in
5 of the septic cases of the series, puncture of the membranes was
the only interference, one of these cases proving fatal.
In this series the operation was always carried out under
hospital conditions with full aseptic and antiseptic precautions. ©
The method should, therefore, be employed only when definite
indications are present.
5. That prolapse of the umbilical cord is always a possibility
in patients in whom the presentation is abnormal or when the
vertex is not fixed.
I should like to express my thanks to Professor Hendry for
allowing me to publish this series and for help and advice during
the preparation of this paper.
REFERENCES.
1. Williamson, H. Journ. Obstet. and Gynaecol. Brit. Emp., 1905, viii,
No. 4, 257.
2. Smythe, H. J. D. Brit. Med. Journ., 1931, i, 1018.
516
INDUCTION OF LABOUR BY PUNCTURE OF THE MEMBRANES
3. Fitzgibbon, G. Journ. Obstet and Gynaecol. Brit. Emp., 1931, xxxviii,
475-503.
4. Smythe, H. J. D., and D. J. Thompson. Journ. Obstet. and Gynaecol.
Brit. Emp., 1937, xliv, 480.
5. Jackson, D. L. Amer. Journ. Surg., 1929, vii, 390-393.
6. Guttmacher, A. F., and R. G. Douglas. Amer. Journ. Obstet. and
Gynecol., 1931, xxi, 485-497.
. Rucker, M. P. Virginia Med. Monthly, 1932, \viii, 736-739.
. Ayo, T. B. New Orleans Med. and Surg. Journ.,
235-238.
. Slemons, J. M. Amer. Journ. Obstet. and Gynecol., 1930, xxiii, 494.
. Morton, D. G. Amer. Journ. Obstet. and Gynecol., 1933, xxvi, 323.
. Wilson, L. Amer. Journ. Obstet. and Gynecol., 1934, xxvii, 245.
. McGoogan, L. S. Nebraska Med. Journ., 1935, xx, 67-76.
13. Jackson, D. L. Amer. Journ. Obstet. and Gynecol., 1934, xxvii, 329.
14. Stroganoff, W. Journ. Obstet. and Gynaecol. Brit. Emp., 1934, xli,
592.
15. Blair, E. M. Canad. Med. Assoc. Journ., 1934, Xxxiv, 49.
1932, Ixxxv,
Obituary.
JOHN BRIGHT BANISTER
Tue eldest son of Howard C. Banister, of Tunbridge Wells,
John Bright Banister, whose maternal grandfather was first
cousin to John Bright, was born at Blundellsands, Lancashire, in
April 1880, and died suddenly on April 16th last. He was
educated at the Merchant Taylors, Blundellsands, and from
thence went to Jesus College, Cambridge, where he gained
honours in the National Science Tripos. Proceeding to Charing
Cross Hospital, he graduated in medicine at Cambridge in 1908
and obtained the degree of M.D. in 1909. In 1910 he became a
Member of the Royal College of Physicians of London and was
elected to its Fellowship in 1928. At the foundation of the British
College of Obstetricians and Gynaecologists in 1929 he was elected
one of its Fellows, and later became a member of its Council.
After filling the posts of house physician and house surgeon at
his hospital he commenced his career as an obstetrician and
gynaecologist as resident obstetric officer. This experience was
increased as registrar and pathologist at Queen Charlotte’s
Hospital and registrar at the Chelsea Hospital for Women, and in
due course he was elected to the staff of all three institutions,
becoming the senior obstetric and gynaecological surgeon at
Charing Cross Hospitai, the senior member of the staff at Queen
Charlotte’s Hospital, and occupying the similar position at the
Chelsea Hospital for Women. He was also gynaecologist at the
Prince of Wales’s Hospital, Tottenham, for 12 years, and gynae-
cologist at the Northwood Memorial Hospital, the Norwood
Cottage Hospital, and obstetric surgeon to the Florence Nightin-
gale Hospital, Lisson Grove. He filled the post of examiner at
the Universities of Cambridge, London, Aberdeen, the English
Conjoint Board, the Society of Apothecaries, and the Central
Midwives Board. A fine examiner, and very fair, he inspired the
candidates with such confidence that he always appeared to get
the best out of them.
518
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=
=
a
x
——
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~
ON
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4 Or:
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OBITUARY
Banister served in France and Egypt during the Great War as
médecin-en-chef, Anglo-French Hospital, Le Tréport, and as
surgical specialist No. 17, British General Hospital, Alexandria.
At the Bath Meeting of the British Medical Association in 1925
he served as honorary secretary of the Section of Obstetrics, and
in 1935 was vice-president of the same section; he also served
the office of vice-president of the Obstetric Section of the Royal
Society of Medicine. He was the author of a ‘Manual for
Midwives’’, which went through several editions; part-author of
the ‘‘Queen Charlotte’s Textbook of Obstetrics’’; and the author
of many papers in the medical journals, the last being published
in this number of the Journal of Obstetrics and Gynaecology oi
the British Empire. At the time of his death he was engaged in
writing a book on ‘‘Obstetric Emergencies’’.
Bright Banister was very greatly attached to the Charing Cross
Hospital, taking a great interest in the medical school and its
welfare, and was most popular with the students. He was vice-
Dean in 1928 and he served his term as chairman of the Medical
Committee.
The death of Banister deprived the profession of one of its
leading obstetricians and gynaecologists. He was an expert
operator, always cool, and faced emergencies with great heart.
He was a fine clinical teacher, a gifted speaker, and a skilled
debater. Such is his professional record, which proves that all
these years he must have been working, more or less, at high
pressure. Some ten years ago he had a serious illness and, per-
haps, a warning. Nevertheless with great courage, as was to
be expected of such a man, he faced his strenuous professional
life without hesitation or complaint, and but few of his friends
knew of what he must always have suspected. When all said
and done, however, he will be remembered by his colleagues,
pupils, patients, and friends for quite other reasons. A fine
figure of a man, standing 6 feet 4 inches in height, Banister
was a most lovable man, had a very great sense of honour,
and was never known to speak ill of anyone, preferring the far
more difficult véle of stressing the good qualities of a man
and submerging any which appeared to be bad. He was always
ready at any time to listen sympathetically to the troubles of
others and, with his wisdom, perhaps, to put a different face on
them; by his generosity to “‘lift a lame dog over a stile’’ and by
his good humour and sympathy, apart from his great success as
a surgeon, he instilled into his patients the greatest confidence.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
He was greatly interested in Freemasonry, being a Grand
Officer. When at Cambridge, Banister was a member of the first
boat of Jesus College when it went head of the river, and later in
life he took up golf. It was after playing a round of golf on Good
Friday that he had his sudden seizure.
In 1913 Banister married Jacqueline M. M. Dix. Many will
remember the delightful hospitality they dispensed at their home
at Tatsfield, which was made all the more enjoyable by that
perfect companionship between husband and wife.
“‘A kinder gentleman trod not the earth.”
C.B.
Tue death of John Bright Banister before the fulfilment of his
term of hospital service and in the plenitude of his powers leaves
a wide circle of friends, colleagues and former students to mourn
the loss of a delightful personality that radiated kindliness and
good humour. Examining with him on many occasions and
appreciating his fair-mindedness and faculty of getting the best
possible out of the weaker brethren, I can well understand his
attraction to students, on whom he was bound to have an
inspiring influence.
Although able to claim Banister as a friend of long standing,
1 learnt most of and saw deeper into his character three years
ago whilst we were both engaged at home with others in settling
the programme for the Obstetric Section at the Melburne meeting
of the B.M.A., during the journey out and the meeting there.
Although the half-dozen British obstetricians who made this
excursion in order to uphold their subject in the Antipodes
had all, from paucity in number, to make themselves more
prominent in discussion than they desired, Banister earned in
full measure his share of credit in the success of this section in
maintaining a full house and interest in its proceedings up to
the last minute of the last day. His massive figure, his forthright
and breezy manner, his clear and concise exposition with such
touch of humour as the occasion might warrant, all had a part
in the strong appeal he made to our Australian brethren. It was,
however, in the course of many talks on many subjects during
our voyage across the Pacific that I came to realize fully the
sense of public spirit and social service in his make-up. Although
other considerations weighed, it clearly had a substantial in-
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fluence in his decision to make the trip. His breadth of outlook
over the objects and beneficial results that might ensue from
such meetings and his regrets that the obstetric faculty from
the homeland were numerically so weak served to indicate how
strong was his sense of public and professional duty. With the
others of us he was determined that our section should be attrac-
tive to the profession in the Commonwealth and that opportuni-
ties of stimulating the interest of our overseas obstetric colleagues
in the British College of Obstetricians and Gynaecologists should
not be missed. With this view in mind (and naturally other con-
siderations) he extended his stay in Australia and included a
visit to New Zealand also, during which he spoke at many
centres in both Dominions to the general appreciation, as I learnt
afterwards from several correspondents. On his return, he was
thereby in a position to give usetul information to the officers
of the College on the conditions of practice and general outlook
of the profession in these two great Dominions. Doubtless it
was for this reason he was put on the small Fellowship Selection
Committee very soon after election to the Council. Subsequent
events indicate that Banister’s public spirit advanced with oppor-
tunities for its exercise. In addition to services to institutions
with which he was associated he served on the Council of the
B.C.O.G., on the Central Midwives Board as the representative
of the Society of Apothecaries and on the Council of the Queen’s
Institute of District Nursing. The Society of Apothecaries
appointed him director of its diploma of M.M. and elected him a
member of its Court of Assistants. These and other bodies will
deplore the loss of Banister and find it difficult to fill the place
of one who gave them excellent service and had attained distinc-
tion and influence among his fellows with the promise of their
steady increase had life and health been granted him. Men with
his experience, sage counsel, powers of clear expression and the
public spirit to give lavishly of time and service are not readily
replaced.
In stressing this phase of his character I have left Banister’s
professional qualities and other attributes to notice by those with
a longer and closer association with him and conclude this
tribute to my departed friend by assuring his widow of our deep
and sincere sympathy in her bereavement.
JouHN S. FAIRBAIRN.
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FRANCIS LIONEL PROVIS
FRANCIS LIONEL PRovis, who died on May 2nd last, at the age
of 65, was for 33 years a member of the staff of the Chelsea
Hospital for Women. He also held appointments as Gynae-
cologist to the Italian Hospital in London, and to the St. Pancras
Dispensary; at the latter institution he established a clinic for
mothers and infants at a time when maternity and child welfare
work was in its infancy, and he took the keenest interest in it up
to the time of his death. He was also for some years Consulting
Gynaecologist to St. John’s Hospital, Twickenham.
He was the son of Dr. Wilton Provis, of Mere, Wiltshire, and
nephew of the late Sir Samuel Provis, formerly the Permanent
Secretary to the Local Government Board which was afterwards
merged in the Ministry of Health. He was educated at
Bromsgrove School and then entered St. Bartholomew’s Hospital
for his professional training, taking the qualification of M.R.C.S.
and L.R.C.P. in 1898. As a student he showed no unusual
promise, but his zest for games took him into the Rugby first
fifteen in the season 1892-93, and gained him a place in the first
eleven of the cricket season of 1893 Later in life he took up golf,
which he played with almost ferocious energy and an unshakeable
determination to win. After holding resident appointments at the
Tottenham (now the Prince of Wales’s) Hospital he volunteered
for service with the R.A.M.C. in the South African War, and was
attached first to Lady Curzon’s Hospital and afterwards to the
Imperial Yeomanry Hospital at Pretoria. On his return at the
conclusion of the war he determined to specialize in gynaecology,
and obtained the appointment of Registrar to the Chelsea Hospital
for Women in May 1902. In the same year he took the qualifica-
tion of F.R.C.S. (Edin.) and that of M.R.C.P. (Lond.) a year
later. After 18 months’ work at the Chelsea Hospital he was pro-
moted to the appointment of Surgeon to out-patients, which he
held for 11 years before proceeding in his turn to the appointment
of Surgeon to in-patients He was always proud of his connexion
with this hospital and felt no hesitation in saying that his
experience in the junior appointments ‘‘taught him his work’’.
With characteristic conscientiousness he spared no pains in follow.
ing the work of such talented exponents of gynaecological surgery
as Bland-Sutton and Arthur Giles, and when his time came to
take charge of wards he was completely equipped for his new
522
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responsibilities. He developed sound clinical judgement as well
as a high degree of technical skill, and to this he added a
meticulous carefulness which impelled him to put his best into
everything that he did, and at times to blame himself without due
cause. For many years the present writer had the privilege of
his assistance in both hospital and private work, and his enthusi-
astic co-operation is now a grateful recollection.
During the Great War he took over the duties of Gynaecologist
to the Waterloo Road Hospital for Children and Women, and
those of Surgeon-in-charge of the Northern Star and Southern
Cross Hospital, in addition to his regular activities. He was also
at the time a Special Constable in the Metropolitan Police Force
and was frequently on duty patrolling the streets of the City.
Provis wrote little and was not often heard in public discus-
sions, although in private he loved nothing better than a good
argument. He took a great interest in the treatment of fibroid
tumours by X-rays, and in conjunction with the present writer
he published one of the earliest records of this method from
English observers; it was published in the Proceedings of the
Royal Society of Medicine. He also interested himself in spinal
anaesthesia and in the use of tubal inflation for diagnostic
purposes and introduced a modification of Rubin’s apparatus
which proved to be very useful. For some years he had charge
of the Venereal Department of the Prince of Wales’s Hospital.
In 1913 he married Miss Gladys Barrett, but there were no
children of the marriage. During the last ro years of his life his
health was precarious and there were frequent interruptions to his
work. After a course of sanatorium treatment he was able to
resume full activity for a time, but later his health began again to
deteriorate, and in 1931 he was compelled from this cause to give
up his appointment at the Chelsea Hospital for Women. During
his remaining years he gamely fought a losing battle against
progressing disability, although he kept in touch with his
St. Pancras clinic until a few weeks of his death.
Provis was one of those men of character and ability who
modestly serve their generation, and serve it well. He thoroughly
enjoyed all he did and possessed a remarkable fund of cheerful-
ness and good humour. The standards which he set himself were
high standards and he never departed from them. Such men as
he leave behind them a record of integrity and efficiency which
men of greater mark often fail to attain.
T.W.E.
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It was my privilege to be associated with Lionel Provis first
as a resident and later as his assistant surgeon at Chelsea Hospital
for Women.
I have never met a man who had such a capacity for enjoying
himself whether at work or play.
The most junior to the most senior member of the theatre
staff of Chelsea Hospital looked forward with pleasure to his
operating sessions on Friday mornings, when they knew they
would receive a cheery welcome from a man who could think
only well of everyone.
In 1924, when he lived in Bentinck Street, he developed what
he believed to be influenza, but what proved later to be the
beginning of an illness which was to limit his gynaecological
work. It was during this time that I assisted him and had many
opportunities of seeing the man who could laugh in the face of
adversity and who refused to allow his happy nature to be other
than what his friends and patients knew.
In the passing of Lionel Provis his colleagues and old patients
have lost a true friend, and we tender our deepest sympathy to
his widow, whose devoted care and attention did so much to
lessen his suffering.
A. GALLETLY.
524
BRITISH COLLEGE OF OBSTETRICIANS AND
GYNAECOLOGISTS
THE Quarterly Meeting of the Council was held on Saturday, 23rd
April 1938 in the College House, with the President, Sir Ewen
Maclean, in the Chair.
The following were promoted to the Fellowship and formally
admitted by the President :
Kenneth Vernon Bailey... . ... Manchester
William Ewart Barnie-Adshez Birmingham
Margaret Glen Bott... ... .... Nottingham
Charles Philip Brentnall ....... .... Manchester
Robson Christie Brown... ... London.
John William Alexander Heater ... Manchester
Richard Glynn Maliphant
Harold Jordan Malkin... ....... Nottingham
Arnold Learoyd Walker ....... .... London
Everard Williams ... ... ... .... London
Arthur Joseph Wrigley .......... London
The following were promoted to the Fellowship and formally
admitted by the President (in absentia) :
William Alfred Gordon Bauld ....... Canada
James Black .. ... ... =... ~=South Africa
Gerald Carlton Melhado Canada
Subodh Mitra ... India
Charles Frederick Minas New Zealand
Herman Brookfield Van Wyck Canada
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
The following were admitted to the Membership :
Yeshwant Narayen Ajinkya
John James Armitage
Elinor Frances Elizabeth nck’
Doris Barbara Brown
William Deans Brown
Henry Canwarden
Mary Evans
Martin Birks ln
Jchn Cameron Loxton
John Miller
Robert William Nichol
Susanne Jean Paterson
Charles Guy Roworth
Peter William Stewart Riley
Linton Morris Snaith
Dorothy Marian Stewart
Revivarma Kunjan Tampan
Robert Atkinson Tennant
William Howie Tod
Alice Woodhead
John Clinton Whyte
The following were admitted to the Membership (in absentia) :
Mary Clare Albuquerque ...
William Davies Cunningham
Ockert Stephanus Heyns
Robert Ancel Logan
Benjamin Edward Meek ...
Elayedath Achuyta Menon
Edward Brettingham Moore
David Fox Standing
Geoffrey Ashburton
Clifford Vincent Ward
The following were elected to the Membership:
F. G. MacGuinness
George Joshua Stream
526
India
Salisbury
Canada
Harrogate
London
Guildford
Manchester
Manchester
Australia
Greenock
London
Edinburgh
Aberdeen
Australia
Manchester
New Zealand
India
Cambuslang
Leeds
London
Canada
India
Australia
South Africa
India
Canada
India
Australia
South Africa
Australia
Canada
Canada
Canada
BRITISH COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS
The following have been appointed the first Blair-Bell
Memorial Lecturers :
Richard Alan Brews, M.D., M.S., F.R.C.S. (Eng.), M.R.C.P., M.C.O.G.,
London.
Thomas Norman Arthur Jeffcoate, M.D., F.R.C.S.E., M.C.O.G.
The Annual General Meeting of the College was held on Satur-
day, 23rd April 1938, in the College House, with the President,
Sir Ewen Maclean, in the Chair.
The following were elected to Council in place of those retiring
by statutory rotation:
Representatives of the Fellows :
Aleck William Bourne .......... London
Arthur Leyland Robinson ... «Liverpool
Representatives of the Members:
Eric Arthur Gerrard ~Manchester
William Cunningham Armstrong... Glasgow
527
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INTERNATIONAL CONGRESS OF
OBSTETRICIANS AND GYNAECOLOGISTS
Tuts Congress was held in Amsterdam from May 4th to May 8th.
The last International Congress of Obstetrics and Gynaecology
was held in Berlin in 1912. On the occasion of the fiftieth
anniversary of the Dutch Gynaecological Society, the opportunity
was taken of again initiating such a Congress, which was held at
the Colonial Institute, under the patronage of Her Majesty the
Queen of the Netherlands.
The proceedings opened on the afternoon of May 4th with an
address of welcome by the General President of the Congress,
Professor Dr. P. C. T. van der Hoeven, after which the Congress
was Officially opened by His Excellency the Minister of Public
Instruction, Professor Dr. J. S. Slotemaker de Bruine. The
Chairman of the Dutch Gynaecological Society addressed the
assembly on the occasion of the jubilee of this Society, and he
was followed by speeches of congratulations delivered by the
ofticial delegates representing various countries.
The proceedings ended with a reception by the Committee of
the Dutch Gynaecological Society, the officers of which were:
President, Dr. K. de Snoo, of Utrecht; secretary, Dr. M. L.
Muller, of Utrecht; and treasurer, Dr. I. A. Wijsenbeek, of
Amsterdam.
The Congress was attended by 463 doctors and they
represented 36 countries.
The following Presidents of the Comen had charge of one
or other of the sections: Sir Comyns Berkeley, London; Pro-
fessor L. Brouha, Liége; Professor G. Cotte, Lyons; Professor
R. P. Farnan, Dublin; Professor J. Frigyesi, Budapest; Pro-
fessor P. Gaifami, Rome; Professor H. Guggisberg, Berne; Pro-
fessor E. Hauch, Copenhagen; Professor S. Ono, Sapporo,
Japan; Professor A. Ostréil, Prague; Dr. I. C. Rubin, New York;
Professor B. Stroganoff, Leningrad; Professor G. A. Wagner,
Berlin; Professor S. E. Wichmann, Helsingfors.
Professor Daniel Dougal and Dr. A. Parkes were the official
representatives of Great Britain, and Dr. Bethel Solomons and
Mr. Eardley Holland, of the British College of Obstetricians and
Gynaecologists.
On May 5th the first main subject, ‘‘Eclampsia’’, was opened
528
CONGRESS OF OBSTETRICIANS AND GYNAECOLOGISTS
by “‘Die Pathogenese der Eklampsie’’ (Dozent Dr. E. Klaften,
Wien); ‘‘Traitement de l’Eclampsie’’ (Dr. Henri Vignes, Paris);
“Traitement de |’Eclampsie’’ (Professor B. Stroganoff, Lenin-
grad); ‘‘Eclampsia, geographical distribution’ (Professor K.
de Snoo, Utrecht) ; (Professor Dr. R. Remmelts, Batavia), which
elicited a very full discussion.
On May 6th the second main subject, ‘‘Thrombosis and
Embolism’’, was opened by ‘‘Sintomi e diagnosi’’ (Professor E.
Cova, Torino); ‘“‘The Aetiology of Thrombosis and Embolism’’
(Professor Daniel Dougal, Manchester); ‘‘Prophylaxie und
Therapie der Thrombose und Embolie’’ (Professor S. E. Wich-
mann, Helsingfors) , followed by a good discussion.
On May 7th, the third main subject, ‘‘Hormones’’, was
opened by ‘‘Die Entwicklung der Endokrinologie und ihre Bedeu-
tung fiir die Geburtshilfe und Gynakologie (Professor Dr. G. A.
Wagner, Berlin); ‘‘Keimdriisenhormone’’ (Professor C. Kauf-
mann, Berlin); ‘‘La Physiologie neuro-humorale de |’appareil
génital femelle’’ (Professor Lucien Brouha, Liége), which gave
rise to a very interesting discussion.
In addition to the three main subjects which were debated in
the great hall of the Institute, a large number of short papers were
read in this hall and in the adjacent classrooms. Among such
papers was one by Professor Miles Phillips, Sheffield, on ‘‘The
Prophylaxis of Constriction Dystocia’’; one by Dame L. McIlroy,
London, on ‘‘The Resuscitation of the Newborn’’, complete with
film, and one by Dr. Bethel Solomons on ‘‘Tubal Pregnancy’’.
There were several interesting films exhibited including a
‘‘talkie’’ on ‘‘Low Cervical Caesarean Section’’ by Dr. J. B. De
Lee, Chicago, which he preferred to designate ‘‘Laparotrachelo-
tomy’’; a film not less interesting on account of the repeated
exhortations of Dr. De Lee to the patient to ‘be brave’ as she
would not be hurt much, the operation being carried out under a
local anaesthetic. The meetings were well attended right up to
the final one.
The social side of the Congress was particularly well catered
for. On the first night there was a conversazione at the Amstel
Hotel. On the second night a very interesting reception was held
at the Rijksmuseum, the wonderful collection of pictures, includ-
ing Rembrandt’s Nachtwacht, which was flood-lit, being greatly
admired. On the third night there was an excursion, in full dress,
to an old castle about 40 minutes’ drive from Amsterdam,
including supper, and what those attending were pleased to think
a dance which, owing to the great number of guests, consisted of
529
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
walking round and round the room, arm-in-arm, to the strains of
concertinas and shouts of encouragement of those taking part, so
that before the meeting broke up many of the guests had walked
several kilometres. On the fourth night the Congress dinner was
held at the Krasnopolsky Restaurant at which 650 people were
present, and farewell speeches were made between the various
courses by various representatives of the different countries, there
being thus ample time to regain one’s appetite for the splendid
dinner which was served.
The following representatives from Great Britain and Eire
attended the Congress: Dr. K. V. Bailey, Sir Comyns Berkeley,
Professor Bride, Dr. M. Datnow, Professor D. Dougal, Mr. A.
Gough, Professor Hendry, Mr. Eardley Holland, Dr. A. Parkes,
Professor Miles Phillips, Professor Herbert Spencer, Dr. J. E.
Stacey, Professor St. G. Wilson. The lady Gynaecologists were
well represented by Dr. A. Bloomfield, Dame L. Mcllroy,
Dr. J. K. Rose, Dr. M. Salmond, and Dr. B. Turner. From
Eire came Professor Kearney, Professor D. V. Morris and
Dr. Bethel Solomons; from Melbourne, Dr. A. M. Wilson.
Everyone was most enthusiastic over the arrangements which
had been made at the Bureau in the hall of the Institute, under
the very able direction of Mejuffrouw A. C. Schippers, who spoke
five languages, helped by a bevy of attractive voluntary
assistants, who worked extremely hard throughout the whole of
the Congress for the information and comfort of those attending.
A Ladies’ Committee looked after the relatives of the doctors
attending the Congress and arranged every day interesting ex-
cursions in which those who wished could take part.
At the plenary meeting on May 7th, Professor Wagner pro-
posed that the Congress should be organized again in four years
time, and that a small Committee should be appointed to decide
the question and the place of meeting. It was suggested that
Dr. van Tongeren should be appointed as permanent secretary.
Professor Wagner’s resolution was carried with acclamation. On
the request of Dr. Ernst Hodkoeppler, the Spanish language was
accepted as one of the official languages for future International
Congresses.
On Sunday, May 8th, a very enjoyable excursion into the
country was arranged, including a visit to the Great Dyke of the
Zuyder Zee and to the fishing village of Volendam, a large
number of the inhabitants of the latter turning out in their national
Sunday garments.
330
CONGRESS OF OBSTETRICIANS AND GYNAECOLOGISTS
All said and done, the great success of the Congress was due to
the untiring efforts of Dr. F. C. van Tongeren, ably assisted by
his assistant secretary Dr. J. G. Salomonson. Owing to the greatly
lamented death of Professor Dr. A. H. M. J. van Rooy, to whom
several affectionate references were made during the proceedings
of the Congress, a great part of the organization fell on Dr. van
Tongeren, and he might be well satisfied with the results of his
labours could he but have heard the enthusiastic praise with
which these were recognized by everyone.
ADDENDUM
‘Height of the Anterior Shoulder and its relation to the
position of the Foetal Heart,’’ pages 287-288 (April 1938) :—
The word and the two phrases in italics are to be added.
page 287, line 13: ‘“‘by a trial labour, the following. . .”’
,, 288, line 12: ‘‘the symphysis, or two-thirds of the
distance between the umbilicus and the
pubis, ...”
ys line 15: ‘‘of the sounds is about 7 inches high, or
three-quarters of the distance above the
pubis. When the head... .”’
ERRATUM
‘Hydatidiform Mole: A Statistical and Clinical Study,”’
pages 265-280 (April 1938). The sentence beginning on line 8
of page 268 should have read : —
... ‘Accordingly,
moles showing mainly cystic change with little epithelial pro-
liferation are benign, while those in which epithelial proliferation
is an outstanding feature are much more apt to exhibit invasive
characteristics, penetrating the uterine wall, causing metastasis
and finally forming true chorion epithelioma.”’
531
BOOK REVIEWS
‘‘A Short Textbook of Midwifery,’’ by G. F. Gipperp, M.B., F.R.C.S.,
M.C.O.G., Assistant Obstetric Surgeon, Guy’s Hospital. Crown 8vo.,
pp. 529+vi. London: J. & A. Churchill Ltd. 15s. net.
There is an absolute glut of obstetrical textbooks on the market. Not only
does every professor apparently feel it his duty to produce such a book, but
in many cities a number of obstetricians join in the competition. It is difficult
to understand the reason for this. Whether it is that the inventing of obstet-
rical forceps has gone out of fashion or that the writing of textbooks has
come in, it is difficult to say. The fact remains that there must be a reason
for all this, and we hope that it is not merely a matter of profit for the
publisher or the author. In schools where there is a definite train of thought
in some direction, it is advisable that such a work should appear, but mostly
there is very little difference between the various compositions.
We all admire the work of Mr. Gibberd and we have little to criticize in
his production, except to say that it is very similar to other textbooks in
being. It is well put together, it has all the most modern methods described,
it is essentially a safe book (which is a great commendation), and it can be
whole-heartedly recommended to any student, or general practitioner, who
requires a well-written work on modern obstetrics. B. S.
“Ideal Weight,’’ by W. F. Curistre, M.D., London: William Heinemann
Ltd., 1938. Crown 8vo. pp. 111+xXii. 5s.
This book has been written primarily for stout people who, while con-
tinuing their ordinary daily activities, are slowly reducing weight under
medical advice and supervision. It explains in simple language the facts of
metabolism and food values, The author has achieved a service to the
medical profession by producing a handbook which may be recommended to
patients. The expositions of elementary physiology and dietetics are clear
and true. The advice proffered is everywhere sane and sensible.
Emphasis is rightly laid upon the reality of the physiological balance
between energy intake, as provided by food, and energy output, as repre-
sented by heat production and muscular work. Realization that obesity
is due to perversion of this balance is the proper basis of rendering any
patient’s weight-reduction permanent. The obese individual must achieve a
knowledge as to which are the foods of high calorie value and which are not.
The relatively small dissipation of energy by exercise is shown by the in-
stances provided of the equivalence between food and exercise. Thus three
lumps of sugar equal a one-mile walk. A glass of milk provides the energy
used up in a three-mile walk. One potato, or half a bar of chocolate, puts
back the calories lost in playing nine holes of golf.
532
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BOOK REVIEWS
Numerous excellent recipes are given. The facts relating to the calorie
values of alcoholic beverages are simply presented. From every point of view
this compact manual for patients deserves high praise. It is worthy of being
read by all doctors. HL. M.
“The Patient and the Weather’ (Vol. IV, Part III), by Wittam F.
PETERSEN, M.D.: Edwards Brothers, Michigan. Price, $10.
If the author of ‘‘The Patient and the Weather’’ is to be congratulated
it will be on the monumental size of the publication and the infinite labour
it represents: there are twelve volumes.
Volume IV contains, within its impressive bulk, sections on post-operative
complications, ectopic gestation and puerperal sepsis which it is our duty to
review. No useful purpose is served by a detailed criticism, sufficient to
admit that while no one disputes that seasons and weather have an influence
on the general resistance, and thereby sometimes influence susceptibility to
infection the occurrence of complications and recovery therefrom. There is
much, however, in this book which will not meet with agreement, one
example for instance, that the pain and rupture of an ectopic gestation bear
a relation to the barometric pressure. The author has been dazzled by his
theory and reads confirmation in chance relations between barometric pressure
and clinical happenings in the illustrating cases. The isolated case-reports
are worthless for the purpose of proof and there is an absence of reliable and
comparative statistics.
The suggestion that all operative intervention other than emergency cases
should be restricted (to what extent?) during certain times of the year is
hardly possible for either hospital or private practice. The proposal that
surgeons should take their vacations in the late winter and spring in order
to lower the mortality-rate will scarcely meet with approval either. And
then we are warned against adopting a one-sided view! ‘‘Just as the meteoro-
logical environment is important so the sex cycle is important, and certainly
no surgeon who is a true physician would subject a woman to an operation
premenstrually when delay to the postmenstrual phase could be arranged.”’
It does not carry conviction and the bewildering charts and graphs merely
add confusion to a most extraordinary book. The sections we set out to
review, like the rest of the volume, are difficult to read, more difficult to
understand, when understood more difficult to accept, and their clinical and
therapeutic value is nil, ‘‘The Patient and the Weather’’ might find a place
in a comprehensive library, but the reader is hardly likely to find it either
lucid or useful, or its recommendations practicable. W. N.S.
Atlas: illustrating the Division of Cancer of the Uterine Cervix into four
stages. (League of Nations Health Organization 1938.) Price 7s. 6d.
The rules for the allocation to stages of carcinomata of the uterine cervix
adopted by the Cancer Commission of the League of Nations, Radiological
Sub-Commission, have been differently interpreted by various centres, As
933
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
this defeats the effort to secure comparability of results, this small atlas has
been prepared for the Health Organization by Dr. Heyman, of Stockholm,
with modifications derived from his experience during recent years.
The stages recommended are.as follows: Stage 1: growth strictly confined
to cervix. Stage 2: (a) involvement of one or other parametrium, but not
to pelvic wall; (b) involvement of vagina in upper two-thirds; (c) endocervical
growth involving corpus. Stage 3: (a) parametrium involved to pelvic wall
on one or both sides; (b) vagina involved in lower third; (c) isolated metastases
on pelvic wall. Stage 4: involvement of bladder or rectum or extension
beyond the true pelvis.
In the past difficulty has arisen in differentiating stages 2 and 3, and if
any doubt occurs the earlier stage should be chosen. The various stages and
clinical types are well illustrated by means of diagrams, and by its means
the atlas offers a possibility of defining accurately the results of radiotherapy
in the treatment of cancer of the cervix on the strict lines of research.
In order to obtain full statistics of such results the committee invites
collaboration of institutes throughout the world, and those interested may
obtain full details and a copy of the atlas on application to the Publications
Service of the League of Nations, Geneva, Switzerland. The atlas is printed
in English, French, and German.
I. G. Williams.
934
=
Review of Current Literature.
Director: FREDERICK Rogurs, M.A., M.D., M.Chir. (Cantab),
F.RES.,
Tuts Review contains the lists of contents and abstracts of the more
important articles from the following journals with which the ‘Journal
of Obstetrics and Gynzecology of the British Empire’? exchanges :—
British.—The Lancet; British Medical Journal.
Canadian.—The Canadian Medical Association Journal; Bulletin Médical
de Quebec.
Australian.—-Medical Journal of Australia; The Australian and New
Zealand Journal of Surgery.
Indian.—The Calcutta Medical Journal.
American.—American Journal of Obstetrics and Gynecology: The
Journal of the American Medical Association; Surgery, Gynecology
and Obstetrics; American Journal of Diseases of Children.
French.—La Gynécologie; Gynécologie et Obstétrique; Bulletin de ta
Société d’Obstétrique et de Gynécologie de Paris.
Belgian.—Bruxelles Médical.
Italian.—Annali di Obstetrica e Ginecologia; Archivo di Obstetrica e
Ginecologia; Revista Italiana di Ginecologia, Bologna.
German.—Archiv fiir Gynakologie; Zeitschrift fiir Geburtshiilfe und
Gyniakologie; Zentralblatt fiir Gynakologie; Monatsschrift fiir Geb-
urtshiilfe und Gynikologie; Miinchener Medizinsche Wochenschrift;
Monatsschrift fiir Krebsbekampfung.
Scandinavian.—Acta Obstetrica Scandinavica.
South American.—Boletin de la Sociedad Obstetricia y Ginecologia
de Buenos Ayres.
Japanese.—-Japanese Journal of Obstetrics and Gynecology.
The Review of Current Literature thus keeps the readers of the Journal
in touch with current literature throughout the world. At the end of the
year an Index of all the subjects contained in the articles of the above
journals is printed. Arrangements are also made to include abstracts of
important articles on border-line subjects, such as Physiology, Biology and
Biochemistry.
LIST OF ABSTRACTORS.
London: J. Beattie, F.R.C.S.; A. C. BELL, F.R.C.S.; R. K. Bowes,
F.R.C.S.; J. Cameron, F.R.C.S.; ALBERT Davis, F.R.C.S.;
F. H. Finratson, F.R.C.S.; B. GILBert, F.R.C.S.; R. J. KELvar,
F.R.C.S.; R. Licutwoop, F.R.C.P.; J. A. Moore, F.R.C.S.;
C. D. Reap, F.R.C.S. (Edin.); F. Rogurs, F.R.C.S.; R. WINTERTON,
F.R.C.S.
Felsted: W. E. CRowTHER, M.B.
Leeds: R. H. B. Apamson, M.D., AND B. JEAFFRESON, F.R.C.S.
Liverpool: M. Datnow, F.R.C.S.; P. Matpas, F.R.C.S.; T. N. A.
JEFFCOATE, F.R.C.S.
Manchester: R. NEwton, M.D.
Glasgow: Jane H.
535
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
The Canadian Medical Association Journal.
Vol. xxxviii, No. 1, January, 1938.
*Salpingitis. Sir Beckwith Whitehouse.
*Pre-eclampsia. W. P. Tew.
*A case of strangulated ovarian dermoid cyst in a child. P. H. T.
Thorlakson.
Vol. xxxviii, No. 2, February, 1938.
*Puerperal sepsis. B. P. Watson.
*A pathological study of carcinoma of the cervix. P. J. Kearns.
“A case of intra-abdominal pregnancy. G. B. Bigelow.
*Uterus didelphys. N. E. Nykiforuk.
*Caesarean section for placenta praevia. H. A. Hamman.
SALPINGITIS.
The general surgeon all too frequently removes a chronically inflamed
appendix and overlooks some form of salpingitis or other lesion in the
pelvis. The differential diagnosis of inflammation in the pelvis, or even
higher in the abdomen, is never an easy or certain matter. In all cases of
women with abdominal symptoms, a combined abdomino-vaginal, or recto-
vaginal examination, should be made, as well as a thorough abdominal
investigation and a careful tracing of the patient’s history. In acute strep-
tococcal infections of the Fallopian tubes, errors of diagnosis may be
fraught with great danger to the life of the patient; and in such cases
drainage must be instituted early and the safer vaginel route may be em-
ployed. When chronic inflammation of the lower abdomen demands
operation, the incision employed should be a vertical one in the midline
below the umbilicus, as this provides access to the appendix and to the |
depths of the pelvis.
Acute salpingitis may be primary or secondary, the latter being an
acute exacerbation superimposed on a pre-existing chronic process. The
former condition is more serious, there seldom being any limiting adhesions
as in the secondary type. The pelvic peritoneum has vastly greater resist-
ing powers to infection than that of the general abdominal cavity. There
are three groups of infecting agents, gonococci, streptococci, and coliform
bacilli. Gonococcal infections present less immediate danger, as they tend
to subside under palliative treatment, leaving closed Fallopian tubes and
extensive adhesions. Streptococcal and coliform lesions usually demand
drainage.
Acute appendicitis and acute salpingitis may present clinical similarities,
but in cases of salpingitis there is seldom the same urgency for immediate
interference. Above all things an accurate diagnosis is essential. If possible
drainage should be effected through the posterior vaginal fornix. Only
when there is double acute pyosalpinx adherent to the pelvic wall, or when
there is evidence of infection having already spread above the pelvic brim,
is abdominal drainage preferable. In the latter case, a small supra-pubic
536
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REVIEW OF CURRENT LITERATURE
median incision should be made, and a drainage tube passed down into the
pouch of Douglas. If pus is oozing from the tubes, the ampullae should be
opened to permit drainage; the tubes should not be removed. When resolu-
tion of infection is followed by a pelvic abscess, the pus should be drained,
if at all possible, by a posterior colpotomy, and in the majority of cases
this is easily effected. Thirty-three cases of pelvic abscess were treated by
vaginal drainage with no deaths, and 3 out of 18 of these patients, who
were within child-bearing age, subsequently became pregnant. One patient
had three children after vaginal drainage of a large pelvic abscess, and 14
out of 22 reported themselves fit and well five years after operation. In-
only one case was a second operation necessary. In 25 cases of abdominal
drainage, there was one death; of the remainder, two subsequently became
pregnant. The percentage of patients requiring subsequent operation was
higher and the standard of good health afterwards was lower in the group
requiring abdominal operation.
Palliative treatment is difficult to appraise, as in hospital, only severe
types of infection, demanding immediate interference are seen. In sub-
acute salpingitis, active operative interference is not advocated, neither
drainage nor removal of the infected tubes being considered necessary,
or even safe. The application of heat by the Elliot apparatus has been a
recent practice. This is an old remedy, as is the vaginal douche, which
is still a measure of great efficacy provided the douches are frequently
administered and are sufficiently hot and copious. Heat applied to the
infected pelvic viscera is the great healing agent whatever be the means
of its application.
Chronic salpingitis, which includes pyosalpinx, hydrosalpinx and
chronically thickened Fallopian tubes densely adherent to the surrounding
structures, is a condition following acute lesions due to contact by organisms
of less virulence than those causing the pronounced and severe types of
infection discussed above. The infecting organism is usually dead, and the
risk resulting from the escape of fluids from the Fallopian tubes during
operation is not great. The Fallopian tube which, as the result of chronic
inflammation, can be felt per vaginam, or per rectum as a swelling in the
pelvis, should always be removed, as it is damaged beyond all functional
value and its presence is associated with considerable pelvic pain, profuse
and painful menstruation and dyspareunia. Abdominal section for remov-
ing all such appendages is, of course, preferable to the vaginal route, be-
cause dense adhesions frequently render the operation of excision extremely
difficult. Fifty-three cases are reported in the author’s series with no deaths.
It was interesting to compare this with 92 cases of unilateral salpingectomy
with three deaths. If the acute cases were not included in this list, there
were 142 consecutive cases of salpingitis with no mortality.
As regards the results of salpingectomy, 83 per cent of cases reported
good or fair in health, 20 per cent were employed on light work, and only
3 per cent remained incapacitated. Of 67 cases in which only one tube
was removed, 13 required additional treatment; hysterectomy in six;
removal of the remaining Fallopian tube in one, and palliative treatment
in five. Following 31 salpingectomies, hysterectomy was required in four
537
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
because of persistent pelvic pain. It may be taken that 17 per cent of
the cases in which salpingectomy had been performed required subsequent
treatment.
The author shows definitely that when hysterectomy is performed at
the same time as salpingectomy, the mortality is very much higher. The
_death-rate from salpingitis when a double pyosalpinx was present and
hysterectomy was performed, was approximately 7 per cent. This death-
rate has been greatly lowered of recent years by performing vaginal
hysterectomy. The uterus is split into two halves, each of which is removed
separately from below. At the same time the inflamed appendages are
separated, usually easily, from the neighbouring viscera. This separating of
the adjacent appendages is more easily effected from below than from above
and with less danger of injuring adjacent viscera: the problem to be faced
is, should one risk a definite mortality of 7 per cent in the hope of com-
pletely eradicating the disease, or should one employ safer methods which,
however, necessitate a second operation in 17 per cent of cases.
Unilateral salpingitis presents great difficulties, and it seems probable
that in such cases bilateral salpingectomy is justifiable, the remaining tube
proving useless from the point of view of fertility in 70 per cent of the
author’s series; 24 per cent of the author’s cases of unilateral salpingitis
required treatment later.
Conservative operations on the Fallopian tubes, such as salpingostomy,
are not regarded with favour. It is true that successes have. been reported,
but it is possible that these loom large in the vision of the surgeon, obscur-
ing the vast majority of cases which are failures.
A very comprehensive and instructive table giving the results of 24
other cases of salpingitis treated between the years 1913 and 1932 is
included.
PRE-ECLAMPSIA.
Pre-eclampsia is a term which signifies a pathological condition in the
mother closely resembling eclampsia. These pathological changes usually
appear in the final third of pregnancy at a time when the placenta is
undergoing senile changes. The cause of pre-eclampsia is still unknown,
although many theories are advanced. Three possible sources are cited,
the baby, the mother, and the placenta, There is no evidence which might
support the view that the baby is the source of the toxin, but on the
other hand, toxaemia may be found, as in the case of vesicular mole,
when a foetus is not present. Considering the mother as the source, one
of the theories advanced is that there is a bacterial splitting of the mucus
in the colon into toxic substances which cause pre-eclampsia; Hofbauer
held the view that the cause was to be found in an excess of pituitary
diuretic substance in the mother’s blood during pregnancy; this theory was
upheld by other workers. Intra-abdominal pressure has been advanced as
a cause. Disturbed protein metabolism is another theory which regarded
an accumulation of rest nitrogen guanidine as the toxic agent. Disturbed
endocrine balance, increased oestrin, or oestrogenic substances, and partial
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REVIEW OF CURRENT LITERATURE
detachment with massive necrosis of a portion of the placenta resulting
in the liberation of autolytic toxic bodies are other hypotheses. Yet others
state that there is hypercholesterolaemia. Thus there are many and diverse
theories.
It is believed that the hepatic function is the best guide to the progress
of toxaemia as it is most sensitive. The index of the functional capacity
of the liver is the rate of disappearance of bile pigment from the blood.
The best renal tests in toxaemias of pregnacy are the urea-concentration
test and the specific gravity volume test, as they reveal approximately the
ability of the kidneys to function within normal limits.
Chemical investigation of the blood and urine have so far failed to
supply useful information. Pre-eclampsia may be considered a precursor
of eclampsia, the pathological changes differing only in degree. Commonly
these changes are general oedema with haemorrhage affecting the liver,
kidneys, blood and heart.
The author is of the opinion that pre-eclampsia is the most common
of all the toxaemias of pregnancy, low-reserve kidney and hypertension
being less common. In pre-eclampsia, primiparous patients are more often
the victims. The systolic blood-pressure is usually higher than in cases
of low-reserve kidney, but lower than in cases of hypertension. The
diastolic reading is proportionately high; albumin is more abundant than
in cases of low-reserve kidney and greater than in those of hypertension;
visual disturbances are common; feelings of lassitude occur early; there is
seldom any history of previous renal trouble in pre-eclampsia as there is
in low-reserve kidney and hypertension. Abnormal increases in body-
weight such as a gain of five to eight pounds, is an early and important
warning. A systolic blood-pressure of 135 to 140 mm. Hg. demands pre-
eclamptic management. The most important therapeutic measure is rest
in bed. The diet should be salt-free, and the intake of protein should be
limited in accordance with the renal damage. When albumin is present
with casts a protein-free diet should be employed for several days and
then protein should be gradually added, beginning with 50 grammes a day,
increasing to 75 or 100 grams, as the patient improves. Carbohydrate,
from 450 to 500 grammes, and fat up to 50 grammes should be allowed daily.
If the condition improves the patient may be allowed to get up, but
activities must be curtailed; if there is no improvement, induction of labour
before term is advocated, as this will enhance the chances of survival
both of the baby and the mother.
The author is of the opinion that the immediate and ultimate outlooks
are quite good provided that treatment is instituted at an early stage
and carried out efficiently. The patient may have several subsequent
pregnancies without the appearance of pre-eclamptic toxaemia.
A full bibliograhy is appended.
A CASE OF STRANGULATED OVARIAN DERMOID CysT IN A CHILD.
A girl of 6% years was admitted to hospital suffering from attacks
of excrutiating pain in the left lower abdominal quadrant, The pain, which
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did not radiate, was intermittent in character, recurring every two or
three minutes. Complete relief was never experienced between the attacks.
She had had several similar attacks during the previous three or four
months.
The abdomen was extremely tender and rigid, and a mass could be
detected in the pelvis on rectal examination. Abdominal section revealed
a blackish-blue twisted ovarian cyst about the size of a tangerine orange.
The left Fallopian tube and left ovary were removed. Pathological examina-
tion showed that the tumour was an ovarian dermoid cyst.
PUERPERAL SEPSIS,
During the last 20 years considerable progress has been made in the
study of puerperal sepsis. Nevertheless, the death-rate from the disease
has not materially decreased. In 1863 Mayerhofer demonstrated micro-
organisms in the lochia of puerperal women. In 1869 Coze and Feltz found
small bodies isolated or arranged in chains in the blood of a patient with
puerperal fever. The same organisms were found in the lochia of infected
women. Pasteur, in 1879, demonstrated the causal relation of these
organisms to puerperal fever. Long before this, however, Charles White in
England, Simpson in Scotland, Semmelweiss in Austria and Holmes in
America demonstrated the contagiousness of purperal sepsis and established
measures for its control. Lister, by his introduction of antiseptic surgery,
the parent of aseptic surgery, provided the means for extending that
control. Obstetrics, however, has not benefited by the work of Lister
to the same extent as has general surgery.
Prevention of infection can be more satisfactorily instituted and prac-
tised when an accurate knowledge of the nature of the infection is obtain-
able. It is our present belief that there are two main types of puerperal
infection: one being due to a virulent strain of aerobic haemolytic
streptococcus and the other to an anaerobic streptococcus. Infections are,
however, sometimes due to other organisms.
Recent work by Lansfield and others has shown that the haemolytic
streptococci may be divided into several groups, A, B, C, D, etc. Only
those belonging to group A cause serious infections; the others appear to
be mainly saprophytic. This group A beta-haemolytic streptoccccus is the
cause of such infections as tonsilitis, scarlet fever, erysipelas, wound infec-
tions and puerperal sepsis. The same organism, when transmitted, may
affect a different organ or system in another individual. The entrance of
this organism is liable to be followed by severe and often fatal infection
and the important problem is the prevention of its entry. It is extremely
rare for autogenous infections with a haemolytic streptococcus already
present in the genital passage prior to labour, to occur. Possibly group B
organisms are those most commonly present, but they cause at most only
mild infections.
The nose and throat are the most common sites for group A haemolytic
streptococci to reside; they may be present in the upper respiratory passages
of persons free from signs or symptoms of infection, as well as in those
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REVIEW OF CURRENT LITERATURE
suffering from tonsillitis or sinusitis. These carriers are as dangerous as
those with acute infections; serological and other tests have proved the
source of infection frequently to be a carrier. Meleney and others have
shown that organisms from the throats and noses of individuals attending
obstetrical cases were identical with the organisms isolated from infected
patients, and further, have traced the infection of surgical wounds to
organisms emanating from the throats of the surgeon and his assistants.
The author briefly cites six cases of puerperal sepsis with five deaths.
The first three patients, of whom two died, were infected from two members
of the nursing staff who were carriers of the same type of haemolytic
streptococcus. The second group of three patients, all of whom were con-
fined in places widely separated, had the same doctor, from whose throat
the same strain of streptococcus was identified as that obtained from the
uteri and blood of the three patients who died. Furthermore, the sister of
one of these women developed severe tonsilitis with acute otitis, from the
pus of which the same streptococcus was isolated.
Colebrook states that all available evidence supports the view that
strains of the haemolytic streptococcus causing severe puerperal infection
have their stronghold in human respiratory passages. At least 85 per cent
of haemolytic streptococcal puerperal infections have their source in the
respiratory passages of carriers or those with active infection. It is the
practice at the Sloane Hospital to have cultures taken at regular intervals
from the noses and throats of doctors, nurses, students and attendants
attached to the obstetrical service. In addition, everyone in attendance
upon a woman in labour must have the mouth and nose properly covered
by an efficient mask, consisting of at least four layers of gauze or of two
layers with a sheet of cellophane or waxed paper between them. It is to be
emphasized that the nose must be properly covered, and that when the
mask becomes moist it should be changed for a fresh one and never
reversed. Improper masking subjects the patient to a terrible risk. The
irreducible minimum of precautions is that every doctor, nurse or other
attendant who approaches the patient, makes an examination, or dresses
her in the puerperium, must be properly masked. The patient herself, should
be made to wear a mask if she has had a quinsy, cold in the head or other
respiratory infection, or if she has come from a home where members
of the family have similar infections. Furthermore, she should be warned
about putting her hands near her genitals, should be forbidden the use of
an ordinary handkerchief, and cultures should be made from her throat.
It now seems certain that the main cause of haemolytic streptococcal
puerperal infection is due to the spraying of organisms from the noses and
throats of carriers or infected persons on to hands, gloves, instruments,
utensils and dressings which come into contact with the patient. Further-
more, it has been shown by Colebrook and White that this strain of
haemolytic streptococcus can be recovered from the dust of rooms occupied
by infected patients. Also these organisms appear to survive for a consider-
able time. Charles White of Manchester, discussing the management of
pregnancy and labour in 1773, advocated ventilation, clean rooms, clean
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
linen, the isolation of patients to separate rooms and removal of infected
cases. When a patient with fever had been removed, all bedding and
curtains were to be washed, and the woodwork cleansed with vinegar. It is
to be noted that this advice was given nearly a century and a half ago.
In addition there are some saprophytic organisms which may, under
certain conditions, become pathogenic. Growing in dead tissue, they produce
extreme foetor in the lochia sometimes associated with the production of
gas; sometimes they cause thrombophlebitis; on rare occasions septicaemia.
These organisms can be grown only anaerobically. Culture, therefore, should
be made under both conditions.
The use of antiseptics, such as mercurochrome does not appear to
diminish the growth of sapropytic micro-organisms. It seems that increase
of trauma especially if associated with prolonged labour is particularly
prone to be followed by infection.
When forceps must be used, every hour of delay adds to the risk, but
it must be admitted that even minor operative interference is liable to be
followed by increased puerperal morbidity. Deep anaesthesia and increased
loss of blood also add to the risk. The skilled obstetrician is he who knows
when to interfere, when to let nature take her course, and conducts all
manipulation with gentleness and care.
Sulphanilamide, given by injection or in tablet form by the mouth in
doses of 3 to 5 grammes every 24 hours, has greatly raised our hopes. Its
use is not entirely free from toxic action and it should not be given indis-
criminately, but in cases in which group A streptococci can be recovered
from the cervix or blood, or when the clinical signs and symptoms of
infection by this organism appear to be positive.
A PATHOLOGICAL STUDY OF CARCINOMA OF THE CERVIX.
Embryology, anatomy and histology must be considered when a study
of the pathology of cervical carcinoma is made. In the region of the
internal os, the Miillerian epithelium, derived from somtaic mesoderm,
meets and joins the solid plug of epithelium known as the Miillerian hill,
which invaginates the posterior surface of the urogenital sinus. These
tissues are replaced by a new body of epithelium which later forms the
columnar epithelium of the cervical canal, and also the squamous epithelium
covering the portio and upper part of the vagina. The cervical and
squamous epithelium should have common embryonic characteristics, which
should again arise during abnormal embryonic proliferations as exemplified
in carcinoma. This seems to explain the reason why cancer of the cervix
and corpus uteri tend to remain each in its own environment and to con-
form to embryonic type.
The cervix is subjected to many irritations, chemical, toxic and trau-
matic, resulting in hyperaemia which leads to epithelial proliferation and
metaplasia, but with a typical arrangement of the cells.
Cervical polypi and erosions are examples of proliferation with a typical
arrangement of the cells. The abnormal inherent and latent properties of
embryonic epithelium may be released by hereditary disposition or irrita-
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REVIEW OF CURRENT LITERATURE
tion. The latter is, to a certain degree, controllable. The majority of
cases of cancer show the presence of a previous inflammatory trauma. Four
degrees of extension of growth are recognized; (1) limitation to the cylinder
of the cervix; (2) invasion of the whole cervical musculature; (3) invasion
of the parametrial structures; (4) invasion of lymphatic glands, and other
viscera or wide dissemination. During seven years it was found that 20
cases presenting themselves were of the first degree, 43 of the second, 12
of the third and 35 of the fourth. Cures for five years were 22.5 per cent
in cases of groups one and two. It was found that 85 per cent of uterine
carcinomata occurred in the portio, 11 per cent in the fundus, and 4 per
cent in the cervical canal. As the majority occur upon the visible portion
of the cervix, macroscopical discernment of its presence is most important.
Final discrimination rests, however, on the histological appearances.
The susceptibility to radium appears to be inversely proportionate to
the degree of embryonic differentiation. The classification of types of cancer
preferred by the author is the histological one of high, mid and low maturity
as taught by Frankl. At the end of five years there were 7.1 per cent of
the high maturity type living, of the mid maturity 12.2 per cent, and of
the low maturity 13.8 per cent. The glandular spread, first to the
lymphatic station in the transverse parametrium, secondly to the glands
near the promontory and in the sacral, iliac and hypogastric regions,
thirdly to the intermesenteric, and fourthly to the coeliac group near
the diaphragm, is extremely irregular. The spread of cervical cancer is
much more rapid and extensive, having a shorter, more direct route to
the gland stations and from thence by metastases, than is a growth in the
fundus uteri.
Deep X-rays appear to have the same effect as radium, though less pro-
nounced. The dosage of radium should be studied by its effect on the
malignant cells as observed microscopically.
A short bibliography is appended.
A CasE OF INTRA-ABDOMINAL PREGNANCY.
A multipara aged 26 was seen on the twenty-second day of estimated
gestation with pain in lower abdomen. A tender swelling the size of a golf
ball was felt in the left fornix. Three days later this was the size of an
orange. At operation a mass of blood-clot, chorionic villi and lymph was
removed from a deep depression on the left side of the uterine body. The
patient died on the third day from an acute thyroid crisis. Post-mortem
examination and pathological findings made it quite clear that pregnancy
had not existed in either Fallopian tube. The sac was not adherent to
either broad ligament, and the only conclusion compatible with the findings
was that of a primary intra-abdominal pregnancy attached to the side of
the uterus.
Uterus DIDELPHYS.
A patient, aged 18, and gravid about eight months, was found on exam-
ination to have two vaginae, a large one and another much smaller, the two
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were connected through an opening about two inches from the larger
vagina. The patient had a flat pelvis.
Delivery was effected after episiotomy and delivery with the forceps.
Packing was necessary for post-partum haemorrhage, and it was found that
the right half of the uterus contained an ovum, the cervix being reached
from the left vagina. The left cervix was closed. The patient had a sister
with a similar condition, who was normally delivered of a full-time child.
CAESAREAN SECTION FOR PLACENTA PRAEVIA,
A patient aged 33 years in her fifth pregnancy, after a labour of 5 hours
had an extremely severe haemorrhage, due to low implantation of the
placenta which could be felt. Attempts to turn the baby and bring down
a leg failed. Caesarean section, after distant transportation of the patient,
was undertaken, and performed by the classical method. The patient was
much collapsed during and after the operation. The placenta was implanted
in the lower uterine segment. Under the stimulation of intravenous saline
infusion the patient made a good recovery.
J. Lyle Cameron.
The South African Medical Journal.
Vol. xii, No. 4, February 26th, 1938.
*Conservative gynaecological surgery. Victor Bonney.
CONSERVATIVE GYNAECOLOGICAL SURGERY.
Once more, and in his wonted trenchant style, Mr. Bonney has wielded
his pen as the apostle of conservatism. The gist of his subject has already
appeared in this journal (Journ. Obstet. and Gynaecol. Brit. Emp., Vol. xliv,
No. 1, p. 1) and need not be closely recapitulated here. Suffice it to say
that he stresses the physical and psychological value of the generative organs
to a woman, strongly deprecating their removal, except in circumstances
which unanswerably merit it. He emphasizes the abuse of hysterectomy,
especially when performed for the cure of prolapse: the unnecessary perform-
ance of total hysterectomy in the absence of a diseased cervix: the treatment
of fibroids by myomectomy up to the limit of the child-bearing age, which
is 41 for the first, and 45 for a subsequent conception: the needless removal
of the right ovary by general surgeons after the removal of, say, the
appendix, becatise of a chance-discovered cyst: the conservative enucleation
of all benign ovarian cysts with preservation of the parent tissue, from
which they spring, and, lastly, the conservative surgery of inflammatory
diseases of the appendages, by salpingotomy, unless all anatomical structure
should be completely and irreparably disorganized.
“To preserve in their fullest integrity the aesthetic and spiritual values
of the wonderful organism confided to his charge . . . this is the grand
ideal of surgery.”’
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REVIEW OF CURRENT LITERATURE
Journal of the American Medical Association.
Vol. cx, No. 4, January 22nd, 1938.
The toxicity of sulphanilamide. E. K. Marshall, W. C. Cutting and Ken-
dall Emerson.
*An evaluation of the safe period. Irving S. F. Stein and M. R. Cohen.
A premature infant weighing 735 grammes and surviving. Samuel J. Hoff-
man, J. P. Greenhill and Evelyn C. Lundeen.
Vol. cx, No. 5, January 2gth, 1938.
Carcinoma of the uterus. George Gray Ward and N. B. Sackett.
The nature of the toxemias of pregnancy. John P. Peters.
The leukocyte response to sulphanilamide. John A. Bigler, Willie Mae
Clifton, and Marie Werner.
The mode of action of sulphanilamide. Edwin E. Osgood.
Vol. cx, No. 7, February 12th, 1938.
*The treatment of pruritus vulvae by alcohol injection. William M. Wilson,
Vomiting of pregnancy. John M. McGowan, J. O. Baker, Arthur M. Torrie
and John Lees.
Vol. cx, No. 8, February 19th, 1938.
*Normal expectancy in the extremely obese pregnant woman. Harvey B.
Matthews and Maurice G. der Brucke.
Birth of six pairs of fraternal twins to the same parents. William Walter
Greulich.
Epidemic diarrhoea in the newborn. Morris Greenberg and B. M. Wronker.
Vol. cx, No, 9, February 26th, 1938.
The menopause and its management. Emil Novak.
The effect of camphor oil on lactation. R. R. Greene and A. C. Ivy.
AN EVALUATION OF THE SAFE PERIOD.
After reviewing the literature on the subject the authors agree that the
commonest time for ovulation to occur in women is 15 days before the next
menstrual period; that the ovum is capable of being fertilized for less than
2 days after ovulation, and that the fertilizing ability of the spermatozoon
lasts for about 3 days. If no deviations from this standard occurred the 11
days before a menstrual period would be a time of complete sterility, and
Hartman has shown that conception cannot occur during an equivalent period
in the rhesus monkey reared in captivity.
_ In women, however, conceptions have been recorded following a single
coitus at all stages of the menstrual cycle, and even during menstruation.
The probability of extracyclic ovulation, either spontaneous or as a result
of the trauma of coitus is admitted, and, moreover, investigations have shown
the great variability of the length of individual cycles, even when the women
insisted that menstruation occurred at regular intervals.
The conclusion is that maximal and minimal periods of fertility do exist,
but that unexpected irregularities may occur at any time in the cycle, which
tends to throw doubt on the infallibility of the safe period. Reliance on the
safe period alone for limitation of families is inadvisable, but the effective-
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
ness of simple contraceptive measures is enhanced if these are employed
during the relatively infertile period.
THE TREATMENT OF PRURITUS VULVAE BY ALCOHOL INJECTION.
Candidates for alcohol injection were selected only after every effort to
determine the cause of the pruritus had failed, and the majority of the
patients had received thorough conservative therapy, including X-rays and
even excision of the vulva.
The average duration of the pruritus in this series was over eight years,
and the patients’ ages varied from 22 to 78 years. In practically all cases
biopsy specimens of the vulval skin showed microscopic evidence of chronic
subepidermal infection.
Ninety-five per cent alcohol was injected under evipan anaesthesia, the
needle being inserted perpendicularly through the skin, and 2 to 4 minims
of the solution being deposited in the subcutaneous tissues, just below the
dermis, at each insertion of the needle, the number and spacing of the injec-
tions depending on the extent of the lesion and the adequacy of the circu-
lation in the affected area. In general not more than one injection per cubic
centimetre was given.
The treatment is followed by transitory swelling of the vulva, seldom by
pain. The irritation usually stops immediately. In the cases treated complete
relief was obtained in over half. Of the remainder there were several recur-
rences necessitating further injections, but failure occurred in only 4 per
cent of cases.
NorMat EXPECTANCY IN THE EXTREMELY OBESE PREGNANT WOMAN.
The report is based on a study of 200 pregnant women, all of whom
weighed more than 200 pounds, the cases occurring in a series of 6,025 con-
secutive deliveries.
Pelvic measurements were about normal in the series, but albuminuria
was present in 35 per cent of cases, hypertension in 35 per cent, and glyco-
suria in 4.5 per cent. Oedema, especially of the lower extremities, was
present in 43.5 per cent of the cases, while there was a higher incidence of
headache, dizziness and gastro-intestinal disturbances.
Abnormal presentations and positions, mainly occipito-posterior and
breech, were present in more than 26 per cent of the cases, and labour
was generally prolonged, not only on account of the large number of mal-
presentations, but also because of the frequent presence of primary uterine
inertia. The incidence of operative delivety in the obese women was more
than four times that of the total cases treated during the period under
review.
The maternal morbidity was 20 per cent, and there were 2 deaths.
The children tended to be heavier than normal; the foetal mortality was
12.3 per cent. The conclusion is that pregnancy in the extremely obese
presents definitely added risks, the kidneys, liver and heart being especially
liable to damage during the ante-natal period, while the high incidence of
malpresentations and a tendency towards uterine inertia prolong labour and
increase its risks.
F. H. Finlaison.
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REVIEW OF CURRENT LITERATURE
The American Journal of Obstetrics and Gynecology.
Vol. xxxiii, No. 4.
Anatomical description of a case of marginal placenta praevia. D. G.
Morton.
Ventral suspension of the uterus with living sutures. E. M. Hodgkins.
A review of 17 cases of interesting anomalies of the female genital tract.
J.C. Masson and D. H. Kaump.
A statistical study of the treatment of placenta praevia. L. L. Mackenzie.
*Clinical classification of cases of carcinoma corporis uteri. H. S. Crossen.
A report on radiation treatment of cancer of the corpus and cervix uteri
from the Brooklyn Hospital. W. S. Smith.
Oral paraldehyde administration in obstetrics. L. H. Douglass and F. W.
Peyton.
The primiparous internal genitalia after forceps delivery. F. B. Nugent.
*Suprarenal cortex therapy in the vomiting of pregnancy. W. Freeman,
J. M. Melick, and D. K. McClusky.
*The diagnostic value of the X-rays in placenta praevia. S, C. Hall, F. W.
Currin, and J. F. Lynch.
Acute oedema of the cervix in pregnancy and labour. W. F. Seeley.
The incidence of ureteral stricture in lower abdominal pain in women,
C. Lintgen.
*Pituitary radiation for the relief of menopausal symptoms. S. H. Geist
and M. Mintz.
Congenital atresia of the oesophagus with tracheo-oesophageal fistula (3
cases). A. H. Rosenthal.
Primary chorioma of the ovary. W. F. Preston and D. M. Gay.
*Granulosa-cell tumour without uterine bleeding. W. B. McDonough.
Peripheral gangrene following pregnancy. J. L. O’Leary.
Sickle cell anaemia with pregnancy. A. W. Lewis.
Actinomycotic granules in a retention cyst of the cervix uteri. R.H. Jaffé.
Late pregnancy complicated by intestinal obstruction due to an opening in
the mesentery in a young primipara. G.H. Bischoff and C. C. Pinkerton.
Bilateral simultaneous tubal pregnancy. W. Levine.
Abdominal pregnancy. Diagnosis confirmed by hysterography. S. L. Fried-
man.
A giant ovarian cyst. C. G, Strickland, F. A. Kassebohm, and Milton
Schreiber.
Cyclic phenomena associated with menstuation, early pregnancy and
induced abortion in a healthy woman. C. G. Hartman and R. Squier.
Persistent foetal tachycardia and neonatal intestinal obstruction due to
internal hernia beneath the umbilical vein. R. B. Schutz and A, M.
Ziegler.
The Elliot treatment as prophylaxis for gonorrhoea in the female. G. A
Williams.
Impacted and incarcerated cervical fibroid complicating pregnancy. Peter
Caruso.
The use of a rubber band for tying the umbilical cord. G. L. Carrington.
Department of Maternal Welfare. Selected Abstracts. Placenta.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Vol. xxxiii, No. 5. :
On certain pharmacological actions of the newer barbituric acid compounds,
C. M. Gruber.
Analgesia with the barbituric acid derivatives and its relation to sudden
death in labour. T. L. Montgomery.
Effects upon uterine motility of urine from dysmenorrhoeic and normal
individuals. Doris Phelps.
The use of parathyroid extract in the control of early nausea and vomiting
of pregnancy. W. Sussman.
A chemical test for pregnancy applied to the determination of oestrin in
the urine of normal and toxaemic patients in the last trimester of
pregnancy. J. E. Savage and H. Boyd Wylie.
The borderline pelvis. J. Bay Jacobs.
Extraperitoneal (Latzko) Caesarean section. A. H. Aldridge.
The endocrine basis of toxaemia of pregnancy. J. J. Vorzimer, A. M. Fish-
berg, E. G. Langrock, and E. M. Rappaport.
A study of dermoid cysts with a suggestion as to the use of X-rays in diag-
nosis. Morris Glass and A. H. Rosenthal.
Rupture of Graafian follicles. Joseph T. Smith.
The relation between infected urine and the aetiology of pyelitis in preg-
nancy. C. M. McLane and Herbert F. Tratt.
*Contraction ring dystocia. C. H. Mackenzie.
*Trichomonas vaginalis vaginitis. R. von L. Buxton and H. A. Shelanski.
*p-carbamino phenyl arsonic acid in the treatment of trichomonas vaginalis
vaginitis. C. Drabkin.
Evaluation of the practical use of the Aschheim-Zondek pregnancy test.
J. W. Mull and H. D. Underwood.
A modification of the Visscher-Bowman pregnancy test, with a report on
513 observations. H. C. Frech.
An analysis of 12 cases of spontaneous rupture of the pregnant uterus.
Abbey D. Seley.
A histopathological study of a case of intrafollicular ovarian pregnancy.
W. A. Warfield and L. T. Wright.
Autotransfusion with blood from large myomatous uteri. A. J. Walling-
ford.
Uterine papillary cystadenoma of the Wolffian body. C. C. Weitzman,
Frederick Sheer, and S. H. Polayes.
Diabetes insipidus and pregnancy. S. D. Soule.
Foetal death due to strangulation during labour. J. B. Pastore.
A simple, safe and economical cord clamp. H. C. Hesseltine.
Special article.
Irradiation of malignant diseases of the female genitals.
Selected abstracts. Ectopic pregnancy.
CLINICAL CLASSIFICATION OF CASES OF CARCINOMA OF Corpus UTERI.
Crossen believes that some form of classification of the stage of advance-
ment of cases of carcinoma of the body of the uterus is absolutely necessary
if any gain is to be derived from an investigation of the results of various
forms of treatment. He agrees that it is not as easy as in cases of carcinoma
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REVIEW OF CURRENT LITERATURE
of the cervix, but he has managed to find six stages which could be made
out on general and microscopical examination of the specimen after removal.
The main points of these stages are: (1) only endometrium involved; (2)
muscle involved but not beyond halfway; (3) muscle involved more than
halfway and maybe to the surface of the uterus; (4) involvement of surround-
ing structures which can be removed: (5) involvement of surrounding struc-
tures which cannot be removed, but when the main tumour can be removed,
and (6) extensive involvement when the main tumour cannot be removed.
The author also believes that every one should try to estimate the probable
stage before operation so that the correct line of treatment can be instituted,
but he recognizes the difficulties of such a procedure. However, he believes
that a fairly accurate estimation can be obtained if consideration is taken of
the time of onset of the symptoms, if a careful bimanual examination is made
under an anaesthetic to determine the amount of extension beyond the con-
fines of the uterus itself, by curettage and microscopical investigation of the
tissue thus obtained, and by special examination methods, such as cysto-
scopy, gastro-intestinal X-rays, etc., in cases in which extension to surround-
ing structures is thought possible. In stage III cases there should be distinct
enlargement and irregularity on bimanual examination, and if the peritoneum
is involved there will be tenderness. He thinks the prognosis following opera-
tive treatment is excellent in stages I and II, good in stage III, fair in stage
IV, and hopeless in stages V and VI. In stage V cases he advocates removal
of the main mass of the tumour to relieve pressure, but he does not advise
the resection of a coil of intestine or a part of the vesical wall except in
exceptional circumstances, Dependence should be placed on deep X-ray
therapy for the eradication of these and the deeper non-palpable extensions.
The author ends his paper by deploring the fact that so many opportunities
of observing and accurately recording facts and findings are missed, thus
losing the opportunity of solving many difficult problems. He feels that if a
city detective bureau was as careless over facts and clues as most doctors
are it would not get far in the detection of crime.
SUPRARENAL CORTEX THERAPY IN THE VOMITING OF PREGNANCY.
There is no doubt that severe vomiting in early pregnancy often causes
great anxiety to all concerned and that a form of medication with quick results
would be welcomed by all. In 1932 Kemp investigated the function of supra-
renal cortex and came to the conclusion that an insufficient amount of its hor-
mone probably had some bearing on the aetiology of this malady. In 1935 two
of the authors of this paper reported a case of pernicious vomiting treated on
this line with complete success, and now they report 78 other consecutive
cases of nausea and vomiting of pregnancy similarly treated. They adminis-
tered Armour’s gland extract in the form of tablets and ampoules, each con-
taining the equivalent of three grains of dried adrenal cortex. The tablets
were given to those who had nausea or only slight vomiting, and who could
be depended upon to keep the tablets down, while the ampoules were given
to the severe cases, but as soon as the vomiting improved the ampoules
were replaced by the tablets. They divide their cases and the results of their
treatment into four groups. In the first group there were 6 cases of nausea
alone; all were treated with tablets only; 5 were cured and 1 failed to re-
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
spond. In the second group there were 41 cases of severe nausea with slight
to moderate vomiting; all were treated with tablets alone; 40 were cured and
one was a failure. This failed case responded very well to treatment with
ampoules. In the third group there were 15 cases of severe nausea and severe
vomiting, and in the fourth group there were 16 cases classified as pernicious
vomiting. Vomiting ceased in all these 31 cases within 3 to 5 days with
injections of the gland extract and consequently their treatment was con-
tinued with the tablets. They report in detail a severe case so treated in
which the gland administration had to be supplemented by vitamin therapy
because of the development of polyneuritis, They discuss the possibility of
the injections causing the amelioration of the symptoms by psychological
means, but they also point out that the severe cases had been treated by
all the usual remedies, including intravenous glucose, before the use of the
gland extract.
THE DIAGNOSTIC VALUE OF X-RAYS IN PLACENTA PRAEVIA.
In 1935 Ude and Urner reported a method of diagnosing by X-rays the
probable position of the placenta in the lower segment in cases of bleeding
during the last trimester of pregnancy. The authors of this paper were im-
pressed with the method and decided to confirm its value. They come to
the conclusion that X-ray studies in cases of uterine haemorrhage assume
great importance as an adjunct to clinical diagnosis and especially as a guide
to treatment. They describe a series of cases with controls and state that
in their opinion there must be a space of 1.5 to 2 centimetres between the
distorted bladder and the head to be of importance for the diagnosis of
placenta praevia. If the presentation is a breech the method is only of
speculative value while if the lie is transverse then it is of no value at all.
They stress the importance of gaining all the knowledge possible of the exact
state of affairs in such cases without doing a digital examination; such an
examination almost always leads to a profuse haemorrhage and the need
of immediate delivery which might be disadvantageous to mother and child.
PITUITARY RADIATION FOR THE RELIEF OF MENOPAUSAL SYMPTOMS.
Fluhmann and others have pointed out that there is an increased ex-
cretion of gonadotropic hormone during the menopause and yet all patients
do not suffer from severe symptoms. The authors of this paper were sur-
prised to find that in their menopause clinic many patients, who were men-
struating regularly, were complaining of headaches, flushes, sweats, and other
vasomotor symptoms. They came to the conclusion that factors other than
the withdrawal of oestrin or the increase of gonadotropic hormone must be
the cause of these symptoms. Because of the changes which are found in
the pituitary gland after castration they considered that this gland was pro-
bably excreting an abnormal amount of hormone and that if its activities
were curtailed by adequate doses of X-rays the symptoms of vasomotor dis-
turbance might be lessened. They treated a series of 75 cases and used 25
other cases as controls. Sweating was markedly decreased in 85 per cent
and in 20 per cent completely disappeared. The frequency of flushes was
decreased in 75 per cent, and in some cases this symptom completely dis-
appeared, In 50 per cent of cases headaches were relieved and in 25 per cent
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REVIEW OF CURRENT LITERATURE
general nervousness was apparently improved. These improvements lasted
from 2 to 6 weeks after a series of 3 X-ray treatments and then the symptoms
gradually returned, but were never as bad as before treatment. The authors
advocate a maximum of 7 series (21 exposures) and in those cases in which
symptoms still return they recommend injections of progynon-B.
GRANULOSA CELL TUMOUR WITHOUT UTERINE BLEEDING.
McDonough reports a case of well-developed bilateral ovarian granulosa-
cell tumours in a woman aged 50, who did not have any vaginal bleeding.
The majority of the cases reported in the literature have been unilateral and
have given rise to definite menstrual symptoms, especially that of post-meno-
pausal haemorrhage. This tumour was composed of polyhedral cells and
irregular columns of cylindrical cells with ovoid and round nuclei. In some
areas these cells were growing in a cylindromatous character while in others
they made up small groups of rosette configuration. In no part was there any
histological evidence of corpus luteum formation.
CONTRACTION DysTOcIA.
McKenzie draws a definite distinction between a contraction and a retrac-
tion ring because he believes the aetiology and treatment of each is so
different. Most authors apparently do not recognize this important distinc-
tion. On his investigation of 36 cases of contraction ring dystocia he was
unable to find an aetiological factor common to the majority, but it is not
clear whether he had investigated the possibility of internal manipulations
under imperfect anaesthesia or the premature administration of oxytocic
drugs. On the other hand he believes that a retraction ring is always the
result of some mechanical obstruction to delivery. His criterion of a contrac-
tion ring is that it must be felt on vaginal examination and must be causing
some difficulty in the natural or operative delivery of the child. In his
series of cases the only constant finding which might have a bearing on
aetiology was that of malpresentation, which was present in 94.4 per cent of
the cases; the commonest being the posterior position in 69.3 per cent. The
author points out that a contraction ring may continue for an indefinite
period, and in one case was found to be still present 24 hours after first being
diagnosed. He has found that the most effective method of loosening the
spasm is the combination of deep surgical anaesthesia with one or two sub-
cutaneous injections of 0.5 centimetre of adrenalin. The condition is a |
serious one as in this series of 36 cases there were 6 maternal deaths; 4
patients dying after rupture of the uterus. It is also extremely grave for the
foetus; in this series the mortality was 64 per cent.
TRICHOMONAS VAGINALIS VAGINITIS.
The authors examined the vaginal secretion of 532 consecutive patients
who came to the gynaecological and antenatal departments. They found the
trichomonad was present in 31.6 per cent, with a rather higher incidence inf
coloured women. They also examined the prostatic secretion of 102 males
and found that 3.9 per cent were positive.
They describe their method of finding and culturing the organism, For
Paice
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
treatment they favour the insufflation of one part of silver picrate with
99 parts of kaolin supplemented by a suppository containing 2 grains of
silver pictrate in a boroglyceride-gelatin base.
p-CaARBAMINO PHENYL ARSONIC ACID IN THE TREATMENT OF TRICHOMONAS
VAGINALIS VAGINITIS.
Arsenical preparations are increasing in popularity in the treatment of
trichomonas vaginitis, and Drabkin describes his results with carbazone. His
treatment was contolled by the examination of repeated Gram-stained smears
when pus cells, the protozoa, other organisms, and a few Déderlein’s bacilli.
Twenty-one cases were examined and treated, including a child of 14 years;
none of them were virgins, and in none of them was gonorrhoea suspected or
found.
The author describes his procedure in detail. It includes soapsud vaginal
douches and rectal washouts, rectal carbazone suppositories, vaginal carba-
zone irrigations and pessaries. After three weeks all rectal therapy is dis-
continued and the vaginal treatment is continued until the next menstrual
period. During the period the patient is instructed to douche night and
morning with a lactic acid solution and to insert one carbazone pessary at
night. After the period she reports for examination. The whole course is
started directly after a period so that it can be carried on uninterruptedly
for 21 days. In all cases the protozoon was absent after two weeks, but treat-
ment was continued until after the next period. Only two cases recurred
curing the follow-up period of many months, and the author believes that
these are due to re-infection from the husband. He stresses the importance
of the treatment of the rectum because of the possibility of its being the
source of infection.
Bryan Jeaffreson.
Surgery, Gynecology and Obstetrics
Vol. Ixvi, No. 2, February 1, 1938.
*Clinical behaviour of early carcinoma of the cervix. W. Schiller.
*Krukenberg tumours of the ovary; clinical and pathological study of 21 cases.
E. Novak and L. A. Gray.
*Obstetric anaesthesia: I. A laboratory method for studying the effects of
anaesthetic and analgesic agents on both the uterus and foetus. B. E.
Bonar and C, M. Blumenfeld.
Vol. Ixvi, No. 2a, February 15th, 1938.
*Some physiological and pathological observations on the urinary tract
during pregnancy. J. M. Hundley, I. A. Siegel, F. W. Hachtel, and J. C.
Dumler.
*Radical obstetrics and national maternal mortality, F. W. Lynch.
*Water balance in relation to the toxaemias of pregnancy. M. E. Davis.
*Abdominal and pelvic pain from a gynaecological viewpoint. A. H. Curtis
*Caesarean section. J. R. Fraser and D. Sparling.
*Syphilis in the pregnant woman. J. R. McCord
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Vol. Ixvi, No. 3, March 1938.
*Studies on the circulation in pregnancy: II. Vital capacity observations in
normal pregnant women. K. J. Thomson and M. E. Cohen.
*Advanced extra-uterine pregnancy. M. A. Novey.
CLINICAL BEHAVIOUR OF EARLY CARCINOMA OF THE CERVIX.
Eight years ago Schiller made his first report on the study of histological
and clinical diagnosis of early carcinoma of the cervix, the pathological im-
portance of the carcinomatous layer, and the possibility of establishing the
diagnosis by means of the iodine test. Schiller is now able to report 43 cases
that have been observed for at least five years or more after the operation.
In all of them iodine tests were made and revealed suspicious-looking patches
on the cervices; subsequent microscopic examination of tissue removed estab-
lished the diagnosis of beginning surface carcinoma of the cervix. In only
one of the 43 patients was there a recurrence, therefore there were absolute
cures in 98 per cent of the cases.
In this paper Schiller gives details of three cases which illustrate clearly
that there is not only a biological but a morphological analogy between early
carcinoma of the cervix and Bowen’s dermatosis. The period of surface
growth is exceptionally long in both types of carcinoma, and the cases
quoted here show that many months may pass before there is any appre-
ciable change in the size of the lesion. Rapid and excessive growth does not
occur until the carcinoma has reached a definite size, a certain amount
of superficial disintegration and some invasive growth. The fact that the
primary stage of carcinoma of. the cervix, which represents 90 per cent of
all carcinomata of the uterus, lasts for some time, makes early diagnosis
possible. To make early diagnosis possible, periodic examinations, at least
twice a year would be necessary, and this would guarantee the early recog-
nition of carcinoma and assure permanent cure probably in 95 per cent of
cases.
KRUKENBERG TUMOURS OF THE OVARY.
This paper is based on the clinical and pathological study of 21 cases ot
Krukenberg tumours of the ovary. The gross and microscopic characteristics
of this tumour are described, emphasis being put on the fact that only a
minority of ovarian cancers secondary to gastro-intestinal carcinoma conform
to the proper concept of the Krukenberg type. While other routes of dis-
semination, such as transperitoneal implantation, may explain the ovarian
tumour in some cares, the authors believe that the lymphatic route is far
more frequently concerned in this, as in other forms of secondary ovarian
cancer and of cancer in general.
Although the majority of cases of Krukenberg tumours are secondary,
usually to some form of gastro-intestinal carcinoma, Novak and Grey believe
that there is strong evidence for primary origin in some cases.
In two of the reported cases there was no evidence of a primary lesion
elsewhere, at operation, and the patients were still in good health several
years after the operation, whereas the prognosis in secondary Krukenberg
tumours is practically hopeless as is indicated by the authors’ follow-up of
their own cases.
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OxBsTETRIC ANAESTHESIA.
A procedure recently described by Rosenfeld and Snyder offers great
possibilities in studying the effects of anaesthetics and analgesics upon the
foetus. Bonar and Blumenfeld relate their experience with this method and
the observation of Rosenfeld and Snyder regarding the existence of appar-
ently physiological intra-uterine respiratory movements which are depressed
or stopped by some of the anaesthetics and analgesics are confirmed. There
is evidence that this method may also be of value in studying the effects
of these agents upon uterine contractions.
Direct and colour motion-picture observation upon animals anaesthetized
by transection of the spinal cord are reported and the advantages and dis-
advantages of the method are discussed.
In order to obtain more accurate data there is need for an instrument
which will graphically record these movements; this may be accomplished in
the near future by using an instrument recently devised by Fenning graphi-
cally to record small changes of volume.
SOME PHYSIOLOGICAL AND PATHOLOGICAL OBSERVATIONS ON THE URINARY
TRACT DURING PREGNANCY.
The authors have made an intravenous urographic study of 27 normal
pregnant women throughout pregnancy and the puerperium, and certain out-
standing facts were brought out by them. They found that the most constant
change in the urinary system was dilatation of the pelvis and calyces of
one or both kidneys; dilatation, tortuosity, and kinking of one or both
ureters; and lateral displacement of these structures. Every patient showed
some deviation from the normal, ranging from a slight dilatation to a marked
degree of hydronephrosis and hydro-ureter, The right kidney and ureter
were more affected than the left. The dilatation of the ureter always began
at the pelvic brim, and a definite significant dilatation of the pelvic portion
of this structure was not found in any of the cases. With the advance of
pregnancy, the dilatation of the upper urinary tract gradually increased,
and the authors were unable to observe that it reached its maximal degree
some weeks antepartum and then remained stationary until delivery. The
authors feel that it is a gradual and progressive dilatation. Following delivery
the urinary system returns to normal.
As pregnancy advances, changes take place in the urinary tract which are
ideal for the development of infection. The authors believe that the majority
of organisms are carried to the kidney by way of the blood-stream.
‘An analytical study of 236 patients with inflammatory disease of the
urinary tract was made by the authors. The incidence of pyelitis with
pregnancy was 3.1 per cent. Of these patients 136 were primigravidae and
100 multiparae, and the degree of dilatation of the upper urinary tract was
greater in the primigravidae.
The treatment of urinary infections is discussed at some length. The
ketogenic diet has been discontinued chiefly because it produces a definite
decrease in the carbon dioxide combining power of the blood, a condition
now desirable at this time. The authors’ experience of mandelic acid has
been limited and not encouraging. Sulphanilamide has been used sparingly,
REVIEW OF CURRENT LITERATURE
as it is still in the experimental stage, and the authors were loath to run the
risk of adding a possible toxic manifestation to an already ill patient.
MATERNAL MorTALITy.
The radical school of obstetrics in America feels that child-birth in the
hands of nature is too crude to fit in with the ideas of modern life, and a
small but active group of obstetricians is doing what it can to alter it.
As a result of this, operative obstetrics has increased, but at the same time
maternal mortality has not decreased.
The well-trained radical insists that it is unfair to judge the movement
by maternal mortality figures because most deaths occur in the practice
of untrained men, nor do they feel responsible that such men join the move-
ment and undertake obstetric operations for which they are not trained.
However, the maternal mortality-rate in America does not compare favour-
ably with other countries, and it is evident that the new school of obstetrics
needs proper moulding by the control of men and procedures which are
causing such a high death-rate. The author states that there is a pressing
need for more well-staffed maternity and obstetric wards in well-managed
general hospitals, so that more men can yearly receive adequate practical
training, and, in addition, he feels that the American College of Surgeons
by constant effort, must make it as difficult for the untrained men to do
major obstetrics as it has made it for an untrained surgeon to do major
surgery.
WaTER BALANCE IN RELATION TO THE TOXAEMIAS OF PREGNANCY.
Pregnancy is normally characterized by a positive water balance. This
retention of water is most marked in the last half of gestation. The
generalized tendency to oedema in pregnant women may be the cause or
effect of this positive water balance. An increased positive water balance is
a characteristic finding in most of the late toxaemias of pregnancy and,
therefore, the restoration of water balance is of prime importance in treat-
ment. Theoretically, this can usually be accomplished by diminishing the
intake of fluids and increasing the output. Arnold and Fey have developed
a therapeutic regimen which consists of a limitation of fluid intake below
the fluid output and an increase of the output by a rapid dehydration of
the patient through purgation, spinal fluid drainage, the intravenous use of
hypertonic glucose solutions, and the intravenous use of magnesium sulphate,
The treatment of these toxaemias by the author and others at the
Chicago Lying-in Hospital likewise emphasizes the importance of establish-
ing a normal water balance, and in this communication the routine treat-
ment which is carried out there for all the toxaemias of pregnancy, is given
in full detail.
ABDOMINAL AND PELVIC PAIN FROM A GYNAECOLOGICAL POINT OF VIEW.
Curtis does not present a comprehensive gynaecological survey of abdo-
minal and pelvic pain, but he has selected topics which he considers merit
attention, among which he discusses pain in the right upper quadrant of
the abdomen, dysmenorrhoea, dyspareunia, post-operative distress, pelvic
toothache, perineal pain, and cancer pain.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
‘It is interesting to note Curtis’s observations on what he describes as
‘‘pelvic toothache.’’ He has coined the expression to cover the essential
symptom in a considerable group of patients who travel from doctor to
doctor without relief. He states that the gynaecologist can often relieve
pelvic pain by resection of the presacral nerve, or by treatment, or removal,
of diseased genitalia, but there are many other deep-seated neurological
affections of the pelvis, which the gynaecologist may detect, but which
belong to the domain of the neurologist or orthopaedic surgeon.
CAESAREAN SECTION.
The incidence of Caesarean section is too high, and while it is admitted
that this operation for the classical indication of pelvic disproportion or
obstruction of the birth canal, under ideal conditions, can be made rela-
tively safe, it is in actual practice associated with a very definite mortality.
The broadening of the indications for the operation has definitely increased
the risk for both mother and child. The authors state that although the
low cervical operation has tended to decrease the risks in the presence of
labour or potential infection, it has not entirely removed them. Many
women subjected to Caesarean section to-day would be more suitably dealt
with by more conservatives measures.
SYPHILIS IN THE PREGNANT WoMAN.
It is generally accepted that the basis of antisyphilitic treatment during
pregnancy, is to prevent syphilis in the baby, and if treatment is begun
before the fifth month of pregnancy and continued weekly until labour
begins, a syphilis-free baby is practically guaranteed. If the treatment is
started early in the pregnancy an alternating course of arsenic and a heavy
metal can be used. Arsenic should be the first and last drug to be used.
If treatment is started late in pregnancy arsenic and a heavy metal should
be used concurrently. There seems tc be no other disease the prevention of
which is more simple than that of congenital syphilis.
STUDIES ON THE CIRCULATION IN PREGNANCY. II. ViTaL CAPACITY OBSERVA-
TIONS IN NORMAL PREGNANT WOMEN.
The vital capacity in normal pregnant women is within the limits set as
normal for non-pregnant women. During the course of normal pregnancy
the observed vital capacity usually remains constant or shows a slight
increase; it decreases after delivery in most cases.
There is an increase in the sub-costal angle during pregnancy, with a post-
partum decrease, and the increase in vital capacity closely parallels the
increase in the value of the sub-costal angle, as does the post-partum
decrease.
The vital capacity in the lying position during pregnancy is approxim-
ately 5 per cent less than in the sitting and standing positions, but changes
in a similar way, and is slightly higher in the standing position than in the
sitting position. Age and parity have no apparent effect on the vital
capacity in pregnancy,
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REVIEW OF CURRENT LITERATURE
ADVANCED EXTRA-UTERINE PREGNANCY.
Extra-uterine pregnancy necessitates a great amount of diagnostic skill,
seasoned judgment and proper handling if one is to avoid a tremendous
mortality-rate. In spite of the fact that each case must be handled indi-
vidually, certain points will be found of value in the diagnosis and treatment
of a well-advanced extra-uterine pregnancy.
The following points are important in making a diagnosis, a history of
rupture in the early months with its accompanying signs and symptoms,
painful foetal movements, extremely easily palpable foetus, tender abdomen
on palpation, palpation and demonstration of a small empty uterus separate
and distinct from the sac containing the foetus, markedly retracted cervix,
failure of the foetal sac to contract and asymmetry of the mass on palpation
and as seen by X-rays. Discussing treatment, Novey states that immediate
operation as contrasted to waiting until the foetus reaches the period of
viability is recommended by some very good authorities. On the other
hand, many favour close observation followed by laparotomy when the child
is thought to be viable. The author thinks that a patient can be safely
carried under close observation to a period when the foetus is viable.
C. D. Read.
Bruxelles Médical.
Vol. xviii, No. 7, December 19th, 1937.
*Accidents attributable to treatment with sulphanilamide. E. Taut.
Vol, xviii, No. 9, January 2nd, 1938.
Preliminary note on a new method for measuring the true conjugate
diameter radiologically. Lambert and Grunberg.
Vol, xviii, No. 12, January 23rd, 1938.
*Two cases of intestinal occlusion in the newborn. Edgar Peetermans.
SOCIETE MEDICO-CHIRURGICALE DU BRABANT.
Report OF MEETING HELD ON NOVEMBER 30TH, 1937.
(i) Folliculin therapy in gynaecology. M. Bourg.
Vol. xviii, No. 13, January 30th, 1938.
*Haematometra resulting from cervical ulceration associated with prolapse.
R. Schockaert.
Vol. xviii, No. 14, February 6th, 1938.
The action of sex hormones on the mind. Pierre Combemale.
*Rupture of the uterus. Jean Rouffart-Marin.
Vol. xviii, No. 15, February 13th, 1938.
*Feminine sterility and the pH of the cervical mucus. J. A. Schockaert
and G. Delrue.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
SOCIETE BELGE DE GYNECOLOGIE ET D’OBSTETRIQUE.
REPORT OF MEETING HELD ON JANUARY 8TH, 1938.
(i) Local anaesthesia in obstetrics. F. Mercken.
(ii) Gonadotropic hormones in the blood in normal pregnancy and in
hyperemesis gravidarum. C. Legrand,
‘ii) Tumour praevia complicating delivery. G. Nolens.
(iv) Spontaneous rupture of the uterus during pregnancy. G. Nolens.
Vol. xviii, No. 16, February 23th, 1938.
*Paroxysmal hypertension following subcutaneous injection of icoral during
labour and the puerperium. E. Schockaert and J. Lambillon.
Vol, xviii, No. 17, February 27th, 1938.
Practical organization and technique of blood transfusion with special refer-
ence to the use of stored blood. Georges Jeannerey.
Vol. xviii, No. 18, March 6th, 1938.
Practical organization and technique of blood transfusion with special refer-
ence to the use of stored blood. (Continued). G. Jeannerey,
*Four cases of perforation of the uterus. M. Rocmans,
ACCIDENTS ATTRIBUTABLE TO TREATMENT WITH SULPHANILAMIDE.
Sulphanilamide is an important drug, and although used in the treatment
of streptococcal infections, is also employed for gonorrhoea, epidemic menin-
gitis, typhoid fever, and urinary infections. Although it sometimes produces
toxic symptoms the author is of the opinion that these are rarely serious.
Deaths following the adininistration of sulphanilamide have been recorded
but in most there is insufficient proof that sulphanilamide was at fault.
In support of this contention the writer draws attention to the deaths fol-
lowing the use of a certain American preparation: in these cases it was
subsequently proved that the toxic substance was not sulphanilamide but
diethylene glycol which was employed as a solvent.
Nevertheless, the drug should be given with caution and the patient kept
under careful observation for signs of intolerance,
Two CasEs OF INTESTINAL OCCLUSION IN THE NEWBORN.
Congenital malformations of this type are of some importance to the
obstetrician since they may account for unexpected neonatal deaths.
In the first case the child vomited small amounts of blood and refused
to take the breast, symptoms commencing on the day after birth. Lapar-
otomy on the fifth day was quickly followed by the infant’s death. Subse-
quent examination revealed congenital atrophy of the whole of the large
bowel.
The second child died on the fifth day with symptoms of intestina)
obstruction. Here again the colon resembled a round ligament in appearance.
In this case there were pleural adhesions, and the writer suggests that intra-
uterine tuberculosis might have accounted for the intestinal lesion.
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REVIEW OF CURRENT LITERATURE
Two cases described by Nolens are also referred to: in one of these the
child vomited meconium before and after delivery.
A syphilitic or tuberculous origin should be looked for when lesions of
this kind occur.
HAEMATOMETRA RESULTING FROM CERVICAL ULCERATION ASSOCIATED WITH
PROLAPSE.
Cervical atresia may occur either at the internal os or external os uteri.
It may be congenital in origin in which case symptoms do not arise after
puberty. The soft enlarged uterus associated with amenorrhoea makes it
difficult to distinguish the condition from pregnancy.
Cervical obstruction may also arise as a result of innocent or malignant
tumours, senile atrophy, obstetrical injury, puerperal infection, and curet-
tage. Cauterization by means of chemical or physical agents is also a
cause. Any operation on the cervix such as dilatation, repair or amputation
may be followed by stenosis.
The amount of blood retained in the uterus varies, but as much as 30 litres
has been recorded. The only treatment usually necessary is dilatation of
the cervix and drainage.
In the case described, a woman of 40 years of age had had prolapse
of the uterus for 18 years. After a period of scanty menstruation amenorrhoea
appeared some months prior to operation. She had uterine prolapse of the
second degree with ulceration in the posterior fornix: an ulcer on the
cervix had healed and closed the external os. The patient was treated by
vaginal hysterectomy and repair of the vagina and perineum, the result being
satisfactory.
RUPTURE OF THE UTERUS,
The patient, aged 35 years, developed signs of obstructed labour in her
tenth confinement. She had a contracted pelvis and each of her nine pre-
vious labours had been complicated. When labour had been in progress for
24 hours, the foetus was found to be lying transversely with one arm pro-
lapsed in the vagina. The case was treated by internal version. Subsequent
examination by the medical attendant revealed a tear in the right lateral
wall of the lower uterine segment. But since bleeding had stopped and the
uterus was well contracted, he packed the vagina and adopted an expectant
attitude.
In 24 hours the patient’s general condition deteriorated and the abdomen
became distended. Abdominal section under spinal anaesthesia disclosed
offensive blood in the peritoneal cavity and a haematoma of the right broad
ligament. Subtotal hysterectomy and drainage resulted in complete recovery.
During blunt dissection of the bladder an opening was made through its
previously damaged wall. This was repaired and there was no subsequent
incontinence.
FEMININE STERILITY AND THE ~H OF THE CERVICAL Mucus.
The reactions of the vaginal and cervical secretions were known a
hundred years ago, and undue acidity as a cause of sterility was suggested by
Donné even at that time.
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The normal pH of the vagina is in the region of 4.5 and the alkaline
' secretion during orgasm tends to diminish the acidity. The optimal pH for
' spermatozoa is 7 to 7.6.
The literature dealing with pH of the cervical mucus and its variations
in health and disease is reviewed.
In their own experiments the authors measured the pH at the external os
electrically, using a cervical electrode. The slightest amount of bleeding
from the cervix interferes with the result. :
Tests carried out on 22 healthy non-sterile women showed the pH at the
external os to vary from 6.1 to 7.4. The presence of infection lowers the pH.
A reading of less than 6 is regarded as being abnormal.
Eighty-three women complaining of sterility, whose husbands had been
proved to be normal, were also examined. Of those in whom the pH was
normal, g2 per cent had a demonstrable cause for sterility such as closed
Fallopian tubes. Of those patients, however, in whom the cervical secretion
was unduly acid, only 47 per cent had another possible cause for sterility.
Even though other factors may play a part, acidity of the cervical mucus
is an important aetiological factor in sterility. When no other causal lesion
is found, the pH of the cervical secretion is abnormally low in go per cent
of cases.
PAROXYSMAL HYPERTENSION FOLLOWING SUBCUTANEOUS INJECTION OF ICORAL
DuRING LABOUR AND THE PUERPERIUM.
Icoral (Bayer) is a powerful cardiac and respiratory stimulant. In addi-
tion to a direct action on the heart, it has a vasoconstrictor effect on
arterioles. Respiration is stimulated through the respiratory centre. It is
useful in treating asphyxia neonatorum, various forms of poisoning, and
circulatory collapse associated with acute infections, pulmonary affections,
and surgical operations.
The authors use it extensively to combat the fall in blood-pressure during
gynaecological operations carried out under spinal anaesthesia. It raises the
blood-pressure by 30 to 40 mm. Hg. and may be given before the spinal
injection.
In obstetrics, however, its use is frequently followed by a paroxysmal
severe rise in blood-pressure. Seven cases illustrating this phenomenon are
described, the clinical features of the reaction being flushing of the face,
severe headache, vomiting, visual disturbances and sometimes loss of con-
sciousness.
This intolerance is ascribed to the disturbance in the equilibrium of the
vasomotor system which is present during pregnancy. In view of this, icoral
should never be used intravenously and even when given subcutaneously,
very small doses should be employed for pregnant or recently pregnant
patients.
Four CASES OF PERFORATION OF THE UTERUS.
In the first case evacuation of the uterus was undertaken for bleeding
and infection following attempts at criminal abortion. In spite of all precau-
tions the sound twice passed through the infected and unusually soft uterine
560
REVIEW OF CURRENT LITERATURE
wall. Subtotal hysterectomy and abdominal drainage were followed by
recovery.
The second patient had a similar history and dilatation of the cervix
and insertion of laminaria tents were followed by signs of peritonitis. When
the uterus was then digitally evacuated the foetal head could not be found
and a tear in the anterior wall of the uterus was palpated. Subtotal hysterec-
tomy and drainage resulted in the patient’s recovery: the foetal head was
found in the abdomen.
The third example of uterine perforation was produced by bougies in-
serted into the uterus on account of hyperemesis gravidarum. The patient
had had two previous Caesarean sections. Signs of peritoneal irritation were
present two days later and during evacuation of the uterus, a hole into the
right broad ligament was discovered. Subtotal hysterectomy and drainage
were successful.
The fourth patient acquired a perforation of the posterior uterine wall
during attempts at criminal abortion. The injury was discovered during
removal of retained products of conception. There was not any infection or
haemorrhage and the patient was treated conservatively with a successful
result.
In the discussions the importance of previous operations on the uterus
and cervix as a factor in uterine perforation is emphasized,
Points in the diagnosis of uterine perforation are (a) the occurrence of
severe lower abdominal pain, (b) the production of pain on movement of the
uterus, (c) the development of peritonitis within 48 hours of uterine inter-
ference, (d) intra-uterine exploration.
In the absence of infection or haemorrhage, the condition may be treatea
conservatively. But if the uterus contains conceptional products which
cannot be removed without risk of further injury, or if the uterine wall is
infected and devitalized, laparotomy is indicated. Subtotal hysterectomy
with vaginal and abdominal drainage is the operation of choice.
J. N. A. Jeffcoate.
Archiv fur Gynakologie
Band 165. Heft 2.
*Follicular hormone and squamous epithelial metaplasia of the corporeal
mucosa. F. Siegert.
*The effect of ovarian function on the lactogenic activity of the hypophysis.
M. Wiegand.
*Preservation of ovarian function after hysterectomy. H. Siegmund.
The significance of achylic chloranaemia (essential hypochromic anaemia) in
gynaecology. A. Hildebrandt.
Relations of the gonadotropic activity of the adrenal cortex to sexual gland
function. F. Hoffman,
*Results of functional tests of the lungs during pregnancy. W. Borgard and
G. Effkemann.
*Investigations of the ovaries and the related organs during old age. J.
Wailart and S. Scheidegger.
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*Reciprocal connexions between hypophyseal and ovarian hormones, P. H.
Langen.
Carbohydrate metabolism during pregnancy. H. Albers,
The ovary and metabolism. H. Rupp and V. Roth.
Functional uterine bleedings. O. Frankl.
FOLLICULAR HORMONE AND SQUAMOUS EPITHELIAL METAPLASIA OF THE CoR-
POREAL Mucosa.
The view which attributed the formation of squamous epithelium in thee
corporeal endometrium to defective differentiation of embryonic Miillerian
epithelium has been abandoned in favour of a derivation from the basal layer
of the cylindrical epithelium. Its formation, in all recorded cases, has occurred
in the presence of hyperplasia of endometrium or myometrium, or of both—
that is, in presence of general glandular hyperplasia, or circumscribed hyper-
plasia near a polyp or myoma, or in endometriosis of the uterine wall. In
all these conditions morbid ovarian hormonic function is present. In only
3 of 19 cases in the literature was the patient aged over 50. In favour ot
the attribution of the metaplasia to excessive follicular hormone activity are
Grumbrecht’s experimental production of squamous epithelial nests in the
endometrium of rats after protracted injection of progynon B oleosum; as also
a case here reported, in which, rather exceptionally, microscopic examinations
of curettings, the whole uterus and the ovary were possible. At the age of
30 a patient reporting hypermenorrhoea and polymenorrhoea had glandulo-
cystic corporeal polypi; a left parovarian cyst was removed. Two years
later similar symptoms were present, and curetting showed hyperplastic endo-
metrium containing zones of squamous epithelium and of adenocarcinoma.
The right ovary, slightly enlarged, contained no corpus luteum but numerous
fibromatous nodules, thought to arise from ruptured or unruptured follicles.
The endometrium showed much thickening and polyposis, although for two
years only one ovary had been present.
THE EFFECT OF OVARIAN FUNCTION ON THE LACTOGENIC ACTIVITY OF THE
HypopHysis.
Wiegand accepts the view that the ovary is primarily responsible for
mammary growth, the development of the ducts being due chiefly to fol-
licular hormone and that of the alveoli to lutein and folliculin: lactation
results from stimulation of the breast, thus prepared, by the antuitary
lactation-hormone, He has recently reported (Zentralb. f. Gynikol., 1937,
2371) that administration of follicular hormone to lactating rats suppresses
the normal increase in lactation-hormone usually shown in the hypophysis.
He now finds that in infantile female rats—which are known to show pro-
nounced mammary development when follicular ripening and corpus luteum
formation are artificially brought about by prolan injections (Selye, Collip
and Thompson, Proc. Soc. Exper. Biol. and Med., 1935, 33) the pituitary
content of lactation-hormone is doubled or trebled. These animals show no
milk secretion; this is, however, demonstrable macroscopically and micro-
scopically, if the animals are killed 36 hours after castration, following
similar treatment. The lactation-hormone, with the castration, disappears
from the pituitary.
562
REVIEW OF CURRENT LITERATURE
PRESERVATION OF OVARIAN FUNCTION AFTER HYSTERECTOMY,
In rabbits, after removal of the uterus ovulation can still be induced by
coitus: this is true whatever nervous and vascular connexions have been
severed or disturbed, provided the vascular pedicle of the ovarian artery and
the accompanying nerve plexus have been spared. There is, nevertheless, a
gradual loss of the readiness with which ovulation can be brought about:
such loss is promptly compensated if gonadotropic hypophyseal hormone is
administered. Siegmund suggests that the nervous and endocrine systems
may be correlated in that centripetal nerve impulses lead via the hypophysis
to freeing of gonadotropic substances promoting ovarian function. If ovary,
vegetative nervous arrangements and pituitary constitute a working system
of which the effects are seen in the uterus, it is conceivable that although
hysterectomy exercises no direct effect on the functional capacity of the
ovary, nevertheless by causing breaches in nerve-paths it may lead to retro-
grade degeneration of regulatory centres in the central nervous system and
thus, through the hypophysis, to gradual paresis of ovarian function. The
practical conclusion is to strengthen the view that healthy ovaries should
not be extirpated when it is necessary to remove the uterus for gradual
elimination of sexual function is more easily compensated than acute
suppression.
RESULTS OF FUNCTIONAL TESTS OF THE LUNGS DuRING PREGNANCY.
A defect in pulmonary function was inferred if increased oxygen con-
sumption followed substitution or oxygen for air in the medium breathed
after exertion, up to 30 watts per second. Some 60 per cent of those tested
during the ninth month or tenth month of pregnancy showed a 14 per cent
deficiency in arteriolization of the blood: this is attributed to deficient
aeration of the bases of the lungs, caused by elevation of the diaphragm.
INVESTIGATIONS OF THE OVARIES AND THE RELATED ORGANS DuRING OLD AGE.
‘« ., . The ovary, even after cessation of its specific activity, that serving
reproduction, does not cease to exercise an effect on sexuality (Geschlecht-
lichkeit). From the morphological modifications we are justified in stating
that even in old age definite functions are exercised by the ovary, having
specific effects on the female organism.’’ The morphological modifications
referred to by Wallart and Scheidegger were noted in 60 women, aged be-
tween 51 and 96, whose endocrine glands were examined microscopically.
Their findings in the ovary differ considerably from the usual report of invo-
lution and shrinkage, followed by almost complete atrophy. The average
dimensions are 15.7x8.3x27 mm. The cortex, far from being a cicatricial
and extinct tissue, shows in the great majority of cases signs of continuing
cellular function and contains cells which are indistinguishable from those
of the ovarian cortex of young subjects: almost invarably small cysts and
tubes lined by cubical, cylindrical or ciliated epithelium are, in addition,
present. Of the abundant corpora fibrosa, chiefly found in the medulla, it
it concluded from special staining that in addition to scar tissue, from
regression of atretic follicles and corpora lutea, they possess a functional
activity: they contain a special connective tissue and a sympathetic neural
network. Small accessory corpora fibrosa, with no encircling garland of
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
vessels, are often encountered in the cortex, and are said to be newly formed,
A rete ovarii is invariably present, is usually well developed, and often
shows proliferative processes: in a few cases adenomata were noted. The
epithelium of the tubes of the rete shows well-marked signs of secretory
activity, and in many cases a pseudo-glomerular disposition. Paraganglionic
tissue is usually demonstrable, and abundant development is usually accom-
panied by a well-preserved rete. Non-striped muscle is as plentiful as in
young subjects, or increased. In seven cases ectopic decidual cells were
found: in these cases the breasts showed signs of secretory activity and the
hypophysis contained so-called pregnancy cells. Unexpectedly the Fallopian
tubes in very many cases showed in combination with submucous sclerosing
processes, secreting, cylindrical and ciliated epithelium, especially towards the
fimbrial end. In one-quarter of cases the epodphoron was as well developed
as in youth: a conspicuous rete formation was a usual concomitant. Neither
together nor separately was pronounced rete or epodphoron formation asso-
ciated with signs of masculinization. In 19 cases myoma, corporeal polyp,
endometriosis or glandulocystic metropathy were present, alone or in com-
bination: cortex, rete, corpora fibrosa and paraganglionic tissue were then
well developed, and in seven cases mammary secretion was noted. In 11
of the 13 cases of this group in which the pituitary was examined, numerous
pregnancy cells were found. The hypophysis, in the whole series, was large
on the average, and the pancreas contained large and apparently active islets
of Langhans. It is said, in conclusion, that if with the menopause the
follicular function in secretion of folliculin and lutein ceases, other sources
must be available in the ovary for production of that part of the female
phaenotype which is of hormonic derivation. The sources are to be found in
the ovary, in the cortex, and in the corpora fibrosa especially; they are
stimulated and regulated by the rete ovarii and paraganglionic tissue.
RECRIPROCAL CONNEXIONS BETWEEN HyporpHYSEAL AND OvARIAN HORMONES.
The increased excretion of the antuitary follicle-ripening hormone after
castration is well known, and many animal experiments have shown that
the hormone again disappears if folliculin be administered. In the human
subject the latter finding has been confirmed by Jones and McGregor, Enige-
hardt and Tscherne, and Biittner. In two castrated women Langen was
able on five occasions, a few weeks to three years after operation, to show dis-
appearance of urinary excretion of gonadotropic hormone as a consequence
of the artificial induction of menstruation by means of follicular followed
_by luteal hormone.
W. E. Crowther.
Zentralblatt fiir Gynakologie.
No. 4, January 22nd, 1938.
Myoma and a rare enormous renal calculus. H. Knaus.
Bleeding from the upper urinary tract of clinically unknown causation dur-
ing pregnancy, O. Brakemann.
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REVIEW OF CURRENT LITERATURE
*Prolapse or a vesical ureterocele. F. Schultze-Rhonhof.
Vesical ureterocele and vaginal cysts. E. Schulthess.
The treatment of cystitis with senile prolapse. W. Lindemann.
No. 5, January 2gth, 1938.
The treatment of acute pulmonary oedema in pregnancy. H. Pliigge.
Panmyelophisis during pregnancy and the puerperium. H. D. Miiller.
Polyneuritis during pregnancy. H, Kramm.
Rare causes of bleeding during delivery. W. Fuss.
*Puerperal peritonitis recurring during menstruation. G. Kahlenberg.
Old popular belief and custom regarding childbirth during the middle ages
in Germany. F. Weindler,
No. 6, February 5th, 1938.
*The pathological picture of cirrhosis annularis subhymenalis. G. Tsutsu-
lopulos and J. Platz.
A typical stenosis of the vagina. J. Novak,
The indication for delivery by Caesarean section in the dying patient.
H. Roemer, junr.
Caesarean section from the point of view of population. F. Kiihbacher.
Wider or narrower indications for forceps delivery. K. Podleschka,
The wider use of the Galea forceps. G. v. Pall.
Two cases of missed abortion after strangulation by the cord round the
neck. A. Sauer.
No 7, February tr2th, 1938.
Intraligamentous tubal pregnancy. W. Frhr v. Massenbach.
The differential diagnosis of haemorrhage in extra-uterine pregnancy.
F. Drazancic.
*Cervical pregnancy. E. Wittrin.
Pelvic contraction, after central dislocation of the hip, as a hindrance to
delivery. P. Drossart.
Locked twins presenting by the heads. G. v. Vajna.
*Intravenous narcosis a la reine. H. Rave.
_ No. 8, February 19th, 1938.
Investigation into the proportion of stroma cells and connective tissue
fibres in normal and pathological proliferation of the uterine endometrium,
with especial observation of glandular cystic hyperplasia. J. Osathanondh,
The question of the secretion of mucus by the corporeal mucosa.
St. Lehwirth.
Stalked transplantation of the endometrium into the cervix in supra-
vaginal amputation of the uterus. M. Matyas.
The simultaneous occurrence of adenomyosis uteri interna with other patho-
logical changes of the genitalia, particularly carcinoma uteri. St. v
Skamnakis.
Vesical apron in prolapse operations. H. Toepfer.
The question of the treatment of pendulous abdomen. R. Hubert.
Fourteen personally observed cases of acute yellow atrophy of the liver.
C, Kent.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
No. 9, February 26th, 1938.
The significance of high frequency of pains in early rupture of the mem-
branes with a normal wide pelvis. A. Wiessmann.
The intra-abdominal application of radium for carcinoma of the cervix.
F. Daels.
The question of the determination of intra-uterine foetal maturity by the
use of X-rays. H. W. Kleist.
The use of sodium evipan for prolonged narcosis in big Operations. A.
Baunach.
The diagnosis of pregnancy by animal injections after Kustallow. H. v.
Wattenwyl.
The value of the Kustallow pregnancy reaction with infusion. O. Hinck.
Whether the Friedrich pregnancy reaction is practically useful. M. Rode-
curt.
No. 10, March 5th, 1938.
Results of implantation of the ureters into the rectum after Coffey-Mayo.
L. Nutnberger. :
A case of ureteric compression by endometriosis externa. H. Hauser.
The late results of the Gobell-Stoeckel pyramidalis fascia plastic operation.
W. Lindemann.
Fatal urinary necrosis following ureteric damage by crushing of a ureteric
calculus during forceps delivery. K. W. Kramer.
The treatment of complicated vesico-vaginal fistulae. L. Milew.
*The diagnostic value of cystography in placenta praevia. K. Jablonski and
E. Meisels.
No. 11, March rath, 1938.
The question of basal metabolism in pregnancy. G. Effkemann and W.
Borgard.
*The administration of ergot intra-partum and in eclampsia. H. Albers.
Wrong diagnosis of appendicitis during the puerperium. P. Hussy.
The aetiology and localization of salpingitis and parametritis. E. Schleyer.
The question of domiciliary or institutional delivery. K. Matolcsy.
A curious method of prevention of masturbation in childhood. O, Jobst.
PROLAPSE OF A VESICAL URETEROCELE.
Schultze-Rhonof describes the case of a girl of 19 years of age who came
under his care for a tumour which had prolapsed through the urethra and
become impacted. The patient gave a history of having noticed a swelling
in this position for five years and that up to the time of her admission to
hospital it had always disappeared spontaneously when she lay down. On
examination the tumour was of the size of a man’s fist and held by a stalk
which passed through the urethra and was attached to the left posterior
vesical wall. The urethra was dilated sufficiently easily to admit one finger
alongside the stalk of the tumour,
Further examination of the surface of the strongly congested tumour
showed a dimple through which he passed a ureteric catheter; muco-
pus and then a considerable quantity of urine came through the catheter.
566
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REVIEW OF CURRENT LITERATURE
The diagnosis of total inversion and prolapse of the bladder through the
urethra was negatived by the finding of a vesical cavity which could be
emptied by a catheter passed into it through the urethra. He therefore
diagnosed the condition as being one of prolapse of a ureterocele.
The condition was treated by resection of the ureterocele and plastic re-
construction of the vesical opening of the ureter. As the tumour was too
large to pass through the urethra it was cleaned with disinfectants at the
vulva and steadied by two stay stitches before the rest of the operation
was carried out through a spurapubic vesical incision. The subsequent
history of the case was entirely uneventful and cystoscopy five weeks after
the operation showed an apparently normal ureteric orifice.
PUERPERAL PERITONITIS RECURRING DURING MENSTRUATION.
Kahlenberg describes the case of a primiparous patient in whom puerperal
sepsis developed on the fourth day after a spontaneous delivery which had
been attended by a midwife. On admission to hospital on the day of
onset of symptoms she was found to be suffering from extensive general
peritonitis and was immediately treated by laparotomy and drainage.
Bacteriological examination of the pus showed a pure culture of staphylo-
coccus albus. After operation the patient’s condition improved, the drainage
tube was removed on the tenth day and the patient discharged well four
weeks after removal of the tube. At the time of discharge the patient had
a right-sided adnexal swelling which gave rise to no symptoms.
Five weeks after her discharge the patient’s first menstrual period after
delivery began. At the same time she developed symptoms pointing to
diffuse general peritonitis. She was treated by another laparotomy and
drainage; investigation of the abdomen revealed no gross naked-eye disease
of any organ. Bacteriological examination of the pus showed a pure culture
of staphylococcus albus. The patient made an uninterrupted recovery and
returned home four weeks after her second operation.
As a prophylactic measure the patient was admitted to hospital for
observation at the onset of her second menstrual period. The patient did
not have any further disturbances after this second operation and the cause
of both her attacks of general peritonitis was never discovered.
THE PATHOLOGICAL PICTURE OF CIRRHOSIS ANNULARIS SUBHYMENALIS.
Tsutsulopulos and Platz describe the case of a patient aged 34 years who
came under their care for nearly one year for atresia of the vaginal orifice
and delayed and scanty menstruation. The patient had suffered from
leucorrhoea for eight years and increasing dyspareunia for two years. She
also suffered from signs of ovarian malfunction with scanty delayed mens-
truation, adiposity and lethagy.
The patient was treated with twice weekly injections of 10,000 inter-
national units of folliculin for five weeks and at the end of this time her
general condition was improved and the hymenal ring which had with
difficulty admitted a finger-tip before treatment now admitted two fingers.
Treatment was continued with a daily dose of 50 to 100 units and a weekly
dose of 10,000 units for seven weeks. At the end of this time the patient
was menstruating regularly every four weeks, the loss lasting 3 or 4 days;
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
the patient herself volunteered that she felt well for the first time for many
years. Her local vaginal condition was unchanged from that found at the
previous examination.
For the next three months she was given 10,000 units of folliculin monthly.
At the end of this time she was subjectively well and her dyspareunia was
absent. On examination a rigid ring at the vaginal outlet could still be felt
though the opening easily admitted two fingers. To shorten treatment
excision of this ring was suggested, but refused by the patient who was
entirely satisfied by her endocrine treatment. The patient has remained
under observation with monthly injections of folliculin.
In view of the good results of endocrine treatment in this case the
writers suggest that this is an alternative method to that of excision as
suggested by Halban for cirrhosis annularis subhymenalis.
CERVICAL PREGNANCY.
Wittrin records a case of cervical pregnancy which occurred in his practice.
The patient had previously had two normal deliveries and one miscarriage
for which her uterus had been curetted nine months before her admission to
hospital. Her last regular menstrual period occurred two months before; this
was followed by slight irregular bleeding beginning 6 weeks later, vomiting
and a general feeling of illness.
On examination the cervix was found to be distended to the size of an
orange with the corpus uteri perched on the top of it and of normal size.
On dilatation of the cervix the finger-tip immediately came upon chorionic
tissue and an alarming haemorrhage was set up which quickly proved almost
fatal. The cervical cavity was emptied of its contained ovum, and as bleed-
ing did not yield to haemostatic injections its cavity and the vagina were
tightly packed with gauze. Before the gauze was inserted the internal os
was identified and was found to admit only a uterine sound.
INTRAVENOUS NarcosIs A LA REINE.
Rave refers to a case of rapid labour in which the patient had been
promised a painless delivery; when the head suddenly became visible at the
outlet, it was found that no pernocton was available. As an experiment the
patient was given an intravenous injection of eunarcon with each expulsive
pain, and as the results were most extraordinarily satisfactory a further trial
of this method was made in 200 cases. The initial dose was given when the
head first became visible and it was found that 1 to 1.5 c.c. were needed
to induce unconsciousness. With the succeeding pains a minimal further
amount was injected to keep the patient quiet; it was found that no more
than 5 c.c. of the preparation were needed. Care had to be taken to introduce
the hypodermic needle well into the lumen of the vein before the first
injection, but after this the patient remained quiescent enough not to disturb
its position.
Out of a total of 200 cases 11 women remained refractory and did not
respond by a satisfactory narcosis. In no case was there any unsatisfactory
result to mother or child. There was no diminution in the regularity or
force of the pains and no bad after effects. There was no case of foetal
asphyxia,
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REVIEW OF CURRENT LITERATURE
THE D1aGNostTic VALUE OF Cystoscopy IN PLACENTA PRAEVIA.
Jablonski and Meisels, working at Lwow, describe their results of radio-
graphic cystoscopic investigation in cases of suspected placenta praevia. In
all 30 cases were examined of which 16 were cases of haemorrhage during the
second half of pregnancy, and 14 were control cases.
They found it possible to determine the presence of a central or lateral
placenta praevia or to determine its absence. Six cases were found to have
a placenta praevia, 7 definitely had not. A marginal placenta praevia cannot
with certainty be diagnosed, especially when it is situated on the posterior
uterine wall. The presence of blood-clot from an accidental haemorrhage
could not be diagnosed.
In one case of ante-partum bleeding without placenta praevia the umbilical
cord was prolapsed, which suggested a wrong diagnosis of a low placenta.
The method employed is to empty the bladder with a soft catheter and
then to inject 40 c.c. of contrast solution before taking an X-ray film with
the patient lying on her back with the legs adducted. With the foetal head
presenting and lying above the pelvic brim the fundus of the bladder is
indented by the foetal head and at no point is it more than 1 cm. from the
vault of the foetal skull. If this distance is increased then there is some
solid object inside the uterus coming between the head and the fundus of
the bladder. In the case of clinical suspicion of placenta praevia the radio-
graphic findings can be relied upon except in the rare event of a prolapsed
cord accompanying a case of accidental haemorrhage when a wrong diagnosis
may be reached.
ErGoT ADMINISTRATION INTRA-PARTUM AND IN ECLAMPSIA.
Albers refers to the suggested employment of ergobasin in the induction
of labour. This alkaloid was first recognized in 1935 as ergobasin tatrate and
sold commercially under the name of basergin. Ergobasin has a very rapidly
stimulating effect upon uterine muscle and produces contractions of short
duration. For this reason it has been suggested that it can be used to
induce labour as well as to hasten the second stage of labour.
After the report by Bauereisen in 1937 it was decided to try the use of
basergin in cases of postmaturity in doses of two drops daily at the University
Clinic in Leipzig. This was tried in 14 cases without any definite results,
the patients not being in any way harmed by this treatment.
A further case of postmaturity which had been thoroughly examined and
found to be normal was given two drops of basergin by mouth. Within
5 minutes she complained of numbness of both hands and both arms, also
of sudden unbearable headache. Within 5 to ro minutes the patient started
to vomit and to have strong uterine contractions coming one each minute
with very short remissions. The blood-pressure rose within 30 minutes from
130/80 mm. Hg. before the admission of basergin to 190/110 mm. Hg. and
albumin, which had previously been absent, appeared in the urine. The
pulse-rate dropped from 90 to 54 beats per minute.
Forty-five minutes after the onset the patient was treated by venesection
and 250 c.c. of blood were removed. After this the pulse-rate gradually rose
to 80 beats per minute and the blood-pressure fell to 185/105, 170/100 and
145/100 mm. Hg. at the end of 2, 3 and 4 hours respectively. The uterine
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
contractions continued at intervals of 2 or 3 minutes until the cervix was
dilated to a diameter of 5 cm. At this stage the foetal heart became irregular
and the patient had an eclamptic fit. A living child was rapidly delivered by
Caesarean section; shortly after delivery she had two more fits. Next
morning, 8 hours after the last fit, the patient had apparently fully re-
covered, she passed urine freely and her blood-pressure was 100/40 mm. Hg.
The writer blames the administration of basergin for the alarming state of
the patient. He thinks that the symptoms of headache and numbness of
the arms and hands were due to a severe vascular spasm, while the rapid
rise of blood-pressure resulted from this same spasm, followed by an experi-
mentally induced eclampsia.
In view of the failure to induce labour in the other cases treated and the
serious results in the case he fully describes, the writer holds very closely
to the older advice to avoid any medication with ergot during labour.
R. H. B. Adamson.
Munchener Medizinische Wochenschrift
August 6th, 1937.
*Cardiac disease and pregnancy. W. Hagedorn.
The treatment of bacillus coli pyelitis with prontosil. H. Turk.
August 13th, 1937.
*A hand-worked breast pump. Kurt Scheer.
August 2oth, 1937.
*The early diagnosis of pregnancy. Jules Samuels.
October Ist, 1937.
Uvalysat in the treatment of urinary complications during the puerperium
and following gynecological operations. Paul Beeking.
October 8th, 1937.
Remarks on the treatment of eclampsia. C. Meyboom.
October 22nd, 1937.
*The menstrual cycle. Jules Samuels,
Electro-surgery. H. Fuchs.
*The drinking foetus. K. Ehrhardt.
The prophylaxis and treatment of intra-uterine asphyxia. E. Vogt.
The treatment of dermatoses of ovarian origin with follicular preparations.
W. Reifferscheid.
November 12th, 1937.
Vitamin C in the treatment of recurrent abortion. L. Ley.
December roth, 1937.
The importance of the rachitic pelvis. A. Mayer.
570
REVIEW OF CURRENT LITERATURE
CarpIac DISEASE AND PREGNANCY.
The main aspects of cardiac disease during pregnancy are touched on by
the author. At the Clinic in Miinster the incidence of cardiac lesions is about
0.72 per cent. The author discusses the differential diagnosis of organic
lesions as opposed to symptomatic changes in rhythm and gives an account
of 62 consecutive cases. Of these 37 were uncomplicated cases of mitral
insufficiency, 10 were cases of combined regurgitation and stenosis, in 4 the
lesion was stenosis, in 2 aortic regurgitation, and in 12 myocardial disease.
In 80 per cent the pregnancy went to term with a foetal mortality of 2 per
cent. In 6 cases (9.2 per cent) the pregnancy had to be terfninated. In 6
cases premature birth occurred, and it is interesting to note that in 3 of
these cases there were renal complications, 2 patients having eclampsia.
Seven patients (11.3 per cent) died of cardiac failure; all the deaths occurred
during the puerperium. In 2 cases death was due to subacute endocarditis.
The prognosis is based on the degree of compensation and the response
to therapy.
THe TREATMENT OF BACILLUS COLI PYELITIS WITH PRONTOSIL.
Nineteen cases of acute and chronic pyelitis or cystitis of bacillus coli
origin were treated by prontosil tablets given orally in the dose of one,
three times daily; 16 cases were cases of urinary infection only; in 3 cases the
urinary infection was complicated by pregnancy. In all the symptoms
rapidly settled and the urine became sterile. No untoward symptoms were
observed.
A HAND-WoORKED BREAST PUMP.
Since the introduction of the electric breast pump with its advantage of
rhythmic action, Prof. Scheer has evolved a hand-worked pump with the
same uses. The only disadvantage seems to be that the pump has to be
clamped on to a table.
THE EarLy DIAGNOSIS OF PREGNANCY.
This paper by Dr. Samuels, of Amsterdam, and one in a later issue of
the journal, are extremely interesting. Both papers are about the uses of a
new test for the presence of hormones in the blood. Briefly it is found that
on an average 145 to 150 seconds is the time taken for the blood oxyhaemo-
globin to be reduced to methaemoglobin when in an isolated fold of’ skin.
This time can be estimated by observing the clamped interdigital fold
between the thumb and forefinger. A light is shone from below and the
spectra observed in a spectroscope. The complete apparatus is called a zylo-
scope. The time interval of 150 seconds is constantly found in men and
post-climacteric women. In women during the active sexual time of life
lengthenings of this time occur typically at menstruation and ovulation to
160 or 180 seconds. Thus during the menstrual cycle a graphic record from
day to day can be made called a cyclogram. During pregnancy the time
of reduction is constantly raised unless abortion occurs. Samuels claims
that diagnosis of pregnancy by this method is certain, easy, and can be
accomplished within a few days of its commencement.
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Besides its value in diagnosing pregnancy this method can be used to
elucidate the menstrual cycle, and in his second paper devoted to this subject
he shows how the time of ovulation can be determined in a particular
patient and that more than one ovulation can occur in one cycle. This
he says he has confirmed at laparotomy. The alteration in reduction time is
due to the hormonic content in the blood rising and may be a complex of all
the hormones,
THE MENSTRUAL CYCLE,
The main aspects of this article have been mentioned in the above
abstract. If Dr. Samuels’s conclusions are correct his method will result in
further information on the menstrual cycle. He points out that in the
stage of puberty 2 ovulations during a cycle are common, and in young nulli-
parous women even 3 may occur. From cyclograms it is probable that sper-
matozoa are most fertile for 2 days and that conception and nidation start
in 3 days. He has also interesting conclusions on the safe period and rela-
tively safe period of the cycle.
THE DRINKING FOETUS.
An interesting experiment in the physiology of the foetus was made in
the case of a patient in whom pregnancy had to be interrupted at the sixth
month. Fifteen hours prior to operation 8 c.c. of colloidal thorium were
injected into the amniotic sac through the abdominal wall. X-rays taken
of the foetus later showed the thorium in the stomach and intestines.
The author points out the possible use of this method to determine intra-
uterine death of the foetus.
Acta Obstetricia et Gynecologica Scandinavica.
Vol. xviii, Supplement 1.
“Hyperemesis gravidarum; a clinical and biochemical investigation. E
Schjott-Rivers.
HYPEREMESIS GRAVIDAZUM. A CLINICAL AND BIOCHEMICAL INVESTIGATION.
Schjott-Rivers has written 2 monograph covering the whole field of the
subject of emesis gravidarum from ancient times to the present day. The
monograph is written in English and covers 248 pages,
The investigations carried out by the writer himself were undertaken at
the University Clinic of Obstetrics and Gynecology, Rikshospitalet, Oslo,
under the encouragement of Professor Anton Sunde. He gives an impartial!
description of the main theories of the causes of vomiting of pregnancy and
refers especially to the work of Dubois, Pinard and Kaltenbach. He traces
the stages of the observation of this condition to the point where biochemical
investigations seemed to yield the greatest likelihood of discovering its
cause. From the biochemical aspect of this condition he gives the results
of the investigation of the concentration of chlorides in the urine and blood
of patients with hyperemesis,
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REVIEW OF CURRENT LITERATURE
Investigation of the chloride output in the urine shows it to be very low
in all untreated cases and when there are fluctuations in the course ot
hyperemesis the chloride output fluctuates as well. The reduced chloride
output is due partly to inanition and partly to loss by vomiting.
The blood chloride values in the sufferer from hyperemesis are subject
to considerable variation. Hypochloremia is a regular finding in the medium
severe and severe forms of emesis. It improves rapidly when the vomiting
ceases. He looks upon hypochloremia as secondary to the vomiting and
not of any particular pathogenic significance.
One chapter is given to the report upon an investigation into the relation
of the non-protein nitrogen in the blood to hyperemesis gravidarum. In some
cases in which these values were strikingly low he thinks these result from
hepatic insufficiency.
Eighty per cent of all cases had urobilinuria but he found no definite
relation between the urobilin output and the nature of the case.
One chapter deals with the investigation of the secretion of the gastric
juice. In most cases free hydrochloric acid was not demonstrated. He
attributed this to neutralization by regurgitated duodenal contents and not
to the absence of secretion. Finally, he reviews 6 cases of hyperemesis
gravidarum which had visual disturbances. He considers that the latter are
an indication of a very severe toxaemia and that prognosis is definitely very
bad. He considers that an ophthalmoscopic examination should be made of
any protra-ted or obstinate case of hyperemesis and when changes are found
the pregnancy should be immediately terminated. He gives the clinica]
history of three cases with nervous lesions, one of which died and the case
histories and post-mortem findings of 5 fatal cases which he observed
R. H. B. Adamson.
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REPORTS OF SOCIETIES
THE ROYAL SOCIETY OF MEDICINE
A meeting of the Section of Obstetrics and Gynaecology of the Royal
Society of Medicine was held on March 18th, 1938, when Mr. A. H.
McINDoeE and Mr. J. BricHt BaNIsTER described
AN OPERATION FOR THE CURE OF CONGENITAL ABSENCE OF THE VAGINA.*
Mr. Banister introduced Mr. McIndoe, who then gave a short account
of the history of congenital absence of the vagina and of the methods of
operation for this condition. In the past, three methods have been used,
(1) Application of free grafts to an artificially produced cavity. (2) Intro-
duction of pedicle flaps. (3) Transposition of the intestine.
All these methods depend on the introduction of a mould for, from 7 to
10 days, followed by intermittent dilatation. Progressive contraction occurs
in all cases, but it was least when the method of intestinal transposition
was used. As a result of experience, free grafts were first abandoned, and
later, pedicle flaps were also abandoned when it was found that they were
subject to partial necrosis. Transposition of the intestine was associated
with high mortality, and a varying result in those cases which survived. Up
to the present time this method has held the field.
The main feature of the new method is the introduction of a mould for
4 to 6 months. The mould is covered by an indwelling skin graft, consisting
of a single piece of split skin; the mould is inserted into a dry cavity and
the perineum sewn over the mould, leaving a small aperture for drainage.
Free skin grafts have a contractile phase, which is greater when they are
applied to concave surfaces than when they are applied to convex surfaces.
The contractile phase is of varying length but does not last more than
six months.
The operation itself is neither difficult nor formidable, and a good non-
contractile but insensitive cavity is the result.
Three cases have been treated by this method, two being still in the
intermediate stage. The completed case was shown, and was seen to be
wearing a full-size vaginal rest with comfort.
An excellent film of the technique of the operation was then shown.
The PRESIDENT congratulated Mr. McIndoe on the excellent result of his
work, while Dame Louise McILRoy, Mr. GREEN-ARMYTAGE and Mr. NEON
ReyNoLDs took part in the discussion which followed,
* See also pages 490-494.
574
REPORTS OF SOCIETIES
Mr. NEON REYNOLDs read a paper on
THE PROBLEM OF Post-MATURITY.
Mr. Reynolds said post-maturity is a term which has for long been used
without there being any consensus of opinion as to what constitutes this
state. Its importance lies in the question as to whether treatment for this
condition, per se, is required. It is not easy, in the first place, to decide
when a pregnancy is post-mature. Even with information regarding the
probable date of impregnation, there are various factors which may arise to
upset one’s calculations. Subsidiary methods, such as examination by
X-rays, are not sufficiently reliable in the present state of our knowledge to
justify their use to the extent of deciding maturity. The grounds upon
which treatment is said to be necessary, lie in the oft-quoted phrase
‘“placental degeneration.’’ There is no pathological evidence of any
degeneration particularly connected with, or due to, apparent post-maturity.
Investigation of placental changes by microscopical methods, does not give
any measure of placental function.
It is suggested that there is no evidence to indicate the necessity for the
induction of labour or for the performance of Caesarean section for apparent
post-maturity, uncomplicated by other considerations such as disproportion.
At the completion of his remarks, Mr. Reynolds showed a number of
slides of placentae, showing the distribution of the vessels after injection.
The PRESIDENT agreed with Mr. Reynolds that post-maturity itself,
offered no indication for active treatment, while Professor BRowNrE and
Mr. Dopps took part in the discussion which followed.
Mr. R. H. PaRAMore read a paper on
LOWER SEGMENT CAESAREAN SECTION.
Mr. Paramore gave details of a special technique of the lower segment
Caesarean operation and discussed certain methods of pre-medication,
preparation for operation and the choice of anaesthetic. Spinal anaesthesia
was used in all cases.
The chief difference between Mr. Paramore’s technique and that of the
ordinary technique, lay in the treatment of the peritoneum. The upper
peritoneal flap of the uterus was sutured to the upper flap of the abdominal
wall, which was opened by transverse incision and no attempt was made
to reconstruct the utero-vesical pouch.
Mr. Paramore’s film was well illustrated by —" placed headings,
and on the whole the photography was clear and enabled the details of the
operation to be easily followed.
The President congratulated Mr. Paramore and remarked upon the value
of his film for teaching purposes, while Mr. GILLIatt, Mr. GREEN-ARMYTAGE,
Professor BROWNE and Professor CHASSAR Morr took part in the discussion
which followed.
575
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NORTH OF ENGLAND OBSTETRICAL AND GYNAECOLOGICAL
SOCIETY.
JANUARY
A meeting of the North of England Obstetrical and Gynaecological
Society was held in Manchester on Friday, January 28th, 1938. The new
President, Dr. CHISHOLM, of Sheffield, took the Chair in succession to the
retiring President, Dr. J. W. BripE, of Manchester.
Mr. F. J. BurKE, of Liverpool, showed a specimen of
A GRANULOSA-CELLED TUMOUR OF THE OVARY.
The patient, aged 54 years, was admitted to hospital complaining ot
severe left sided abdominal pain which had been present for 24 hours.
During this time she vomited five times. There was a history of four similar
attacks of abdominal pain and vomiting with the pain becoming progres-
sively worse with each attack. For the past six months the patient had
noticed an abdominal tumour and, from time to time, had been troubled by
frequency of micturition, otherwise her general health had been satisfactory.
She had had eleven full-time deliveries and two miscarriages.
Menstruation had always been normal and ceased with the last pregnancy
at the age of 42 years. At the age of 50 years, irregular uterine bleeding
commenced and continued for four years. This bleeding was, at first, small
in amount and appeared after infrequent intervals, but later it occurred
fairly regularly every three months and lasted for five to seven days. This
condition continued until within four months of admission to hospital, when
the loss became excessive and lasted for 14 days at intervals of four to six
weeks. Thus there was a clear history of post-menopausal bleeding for
four years, commencing eight years after the menopause.
On examination, the patient was obese, but there was no difficulty in
palpating a firm, slightly tender tumour, occupying the lower abdomen.
The uterus was of normal size and appeared to be unconnected with the
large tumour. The cervix was healthy and there was some descent of the
anterior and posterior vaginal walls.
A diagnosis of torsion of the pedicle of an ovarian tumour, possibly of
the granulosa cell type, was made.
At operation, a large firm rounded tumour was found replacing the left
ovary. It had the colour of a normal pregnant uterus, was 6 to 8 inches
in diameter, freely mobile, and entirely free from adhesions. The pedicle
was not twisted. The uterus was of normal size and the right ovary was
atrophic. There was no evidence of malignant deposits in the peritoneal
576
REPORTS OF SOCIETIES
cavity. Bilateral salpingo-odphorectomy and subtotal hysterectomy were
performed.
Examination of the fresh specimen revealed it to be an encapsulated
tumour with a central core of firm fibrous texture, surrounded by a number
of loculi filled with blood-clot, no doubt the result of recent torsion.
The uterus had a smooth endometrial lining with no evidence of gross
hypertrophy.
The microscopical findings seem to confirm the diagnosis of granulosa-
celled tumour.
Discussion. Opening the discussion Professor DouGat referred to two
cases occurring in the childbearing period.
Professor CLAYE described a _ granulosa-celled tumour which caused
continued bleeding after a menopause induced by radium.
Miss RuTH NICHOLSON described a similar tumour which was removed
during pregnancy, when it was considered to be benign, a view which was
confirmed by Dr. Schiller after examination of the section. Unfortunately
the tumour recurred with widespread metastases after delivery.
Professor Mites Puitiprs and Mr, N. E. Epwarps described further
instances of this condition.
Dr. E. A. GERRARD showed
Two LarGeE TuMourRS COMPLICATING PREGNANCY.
1. Large Paraovarian Cyst associated with a Placenta Accreta.
The tumour weighed 18 pounds. It had burrowed between the layers of
the right broad ligament and under the floor of the utero-vesical pouch.
After it had been removed lower segment Caesarean section was performed.
The placenta was found closely adherent and separation was impracticable,
so hysterectomy was performed. It was found necessary to pack the cavity
from which the cyst was removed. Microscopic sections of the placental
site showed villi invading the myometrium.
2. Large uterine Fibroid removed during Pregnancy.
The tumour proved to be a large fibroid growing from the fundus, to
which its attachment measured 3 inches by 2 inches. Myomectomy was
performed at the twentieth week of pregnancy. Two units of proluton were
given daily for a week after operation. Pregnancy continued normally to
term. Delivery was effected by Caesarean section. |
Discussion. The PRESIDENT considered that labour after myomectomy
should be handled expectantly and that Caesarean section was not always
necessary.
Professor DouGat said that in his experience the removal of subperitoneal
tumours seldom disturbed a coexisting pregnancy.
Professor Mites Puitiprs did not consider Caesarean section was neces:
sarily indicated after myomectomy during pregnancy. In his opinion the
577
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
exhibition of corpus luteum had little effect after the fourteenth week of
pregnancy.
Dr. JEFFcoaTE described two similar cases of large fibroids removed during
pregnancy without disturbance.
PROFESSOR DouGat showed a specimen of
INCOMPLETE CERVICAL ABORTION
The specimen consisted of a uterus removed by hysterectomy from a
parous woman aged 39 years who had complained of irregular bleeding for
six weeks. It consisted of a black, necrotic and stinking mass found
adherent to the anterior lip of the cervix, the remainder of the uterus being
apparently normal.
It was evident that the condition was not a carcinoma and subsequent
microscopic examination showed it to consist of blood-clot and chorionic
villi, the latter being in organic union with the vaginal cervix, without any
intervening stratified epithelium. One at least of the villi was swollen and
myxomatous with epithelium in a state of considerable proliferative activity
and the adjacent cervical tissue was congested, infiltrated with leucocytes;
it also contained large spindle cells resembling the so-called wandering cells
met with so frequently in chorion-epithelioma. Large epitheloid cells were
also present in the lumina of several small veins.
The endometrium lining the cavity of the uterus was somewhat thickened
but its surface quite smooth. The glands were much distended and appeared
to represent an exaggerated proliferative phase.
There was nothing of note in the ovaries.
The occurrence of placental tissue on the vaginal cervix must be ex-
tremely rare and the only similar case I have been able to find is one
described by J. D. Parker in the Journal of the American Medical Associ-
tion, July 16th, 1932. In that case there was a history of severe epimenor-
rhagia which began two months after a normal delivery and persisted
until operation 10 months later. A placental fragment measuring 3 by 5
centimetres was found firmly adherent in a cervical laceration and Parker
concluded that in its passage from the uterine cavity after labour the frag-
ment had been grasped in a contracting and lacerated cervix and had there-
after followed the usual course of skin grafts.
Such a simple explanation cannot be applied in the present case as there
was apparently no history of a recent uterine pregnancy and the bleeding
was only of six weeks duration. There were these possibilities in this case :
(1) It was a very early uterine pregnancy with active, probably hydatidi-
form, chorionic villi implanted in the cervix.
(2) It was a case of primary cervical pregnancy with incomplete
abortion. Such cases have been described, but as the ovum usually imbeds
itself in the mucosal lining of the cervical canal, the appearances in the
present case could only be produced by rupture of the gestation sac through
the squamous epthelium of the portio.
578
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REPORTS OF SOCIETIES
(3) It was a case of chorion-epithelioma, either primary or secondary.
The chorionic epithelium is undoubtedly very active but the microscopic
picture is more suggestive of hydatidiform degeneration than of chorion-
epithelioma.
Dr. S. W. Wricut described
A CaAsE oF LocKED TwINns
The patient was a primigravida aged 34 years; toxaemia commenced
at the thirtieth week of a twin pregnancy; the diagnosis was confirmed by
X-ray examination. The toxaemia improved under treatment. Labour was
medicinally induced. There was an exacerbation of symptoms after the
onset of labour. Three hours later the patient suddenly collapsed. After
20 hours the first child was born up to the umbilicus; the heads were locked
above the brim. They were manually disimpacted and both infants were
delivered.
On the sixteenth day of the puerperium a vesico-vaginal fistula with a
diameter of a quarter of an inch was discovered. This was successfully
repaired four weeks later.
The speaker thought that oligohydramnios of the second sac was the
factor responsible for the locking.
Discussion. The case was discussed by the PRESIDENT who considered
the fistula was due to trauma in labour.
Professor DouGat referred to two of his own cases and confirmed that
change in foetal position might occur quickly after an X-ray examination.
Mr. JEAFFRESON, of Leeds, considered the fistula in Dr, Williams’s case
was due to a spontaneous rupture of the lower segment.
Mr. Percy Matpas, of Liverpool, read a paper on
THE MASCULINE PELVIS IN WOMEN.
The recognition that some pelves in women exhibit male characters
is mainly due to the pioneer work of Berry Hart. In a paper entitled
“Atypical Male and Female ensemble,’’ published in 1914, Hart described
certain cases of pseudo-hermaphroditism in which the pelvis as well as the
external genitalia was of the male type. In a later paper published in
1916 entitled ‘‘Inversion of the ilium and sacrum, ischium and pubes (ilio-
sacral and ischiopubic bony segments)’’ he describes a pelvis exhibiting
male characters obtained from a woman dying after a pubiotomy. He
supplemented this description with an account of six further pelves.
There is, however, still far from general agreement as to what shall be
taken as the characteristics of the so-called masculine pelvis in women
and a review of the subject in the light of three recent cases may be timely.
Most obstetric textbooks refer to pelves of this type but do not go further
than the statement that they may be funnel shaped or that some relative
or absolute narrowing of the transverse diameter of the pelvic brim may
579
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
be present. The very important paper by Caldwell and Molloy on ‘‘Ana-
tomical Variations in the Female Pelvis’’ has brought the subject into
prominence. They describe a large group of pelves as android, possessing
male characteristics. The criteria given by authors for the android pelvis
are shortening of the posterior section of the brim due to the forward
position of the sacrum, the tendency for the anterior or pubo-iliac segments
of the brim to be straight and to pass backward from the symphysis at an
acute angle, giving rise to a narrow fore-pelvis; thirdly the tendency for the
sacrum to be vertical.
Thoms in 1933 described a series of cases in which transverse narrowing
of the inlet was found commonly associated with occipito-posterior positions
and he considered many of these pelves belong to the male type or the
inverted pelvis described by Berry Hart. In a later paper, published in
1935, Thoms does not include the male type in his classification and adopts
a classification of pelves based mainly on the pelvic index, i.e. the relation
of the true conjugate diameter to the transverse diameter of the brim, a
classification based on that of Turner of Edinburgh.
There is still certainly room for debate as to what constitutes the mas-
culine pelvis and to what extent the use of the term is of value. Is it
sound to apply the term to the pelves of women who exhibit no other male
characteristics ?
In Hart’s discussion of pelves of this type, he draws freely upon the
papers by Derry on the sex characters of the innominate bones and sacrum,
the observation of J. A. Thompson on the sex characters of the foetal pelvis,
and the papers by Elliot Smith and Wood Jones on the sex of the pelves
of Nubian women. In his pubiotomy pelvis the only male feature was the
small and fully curved sacro-sciatic notch. There is general agreement among
anatomists, mainly based on papers already referred to, that the shape of
this notch constitutes the best guide to the sex of innominate bones. Hart
pointed out that the greater size of the female pelvis is not only a question
of a wider pubic arch and a broad sacrum but is due in great part to the
larger ilium which is associated with this larger sacro-sciatic notch. The
other pelves which he described all exhibited male ilia but typical broad
female sacra. His observations are perhaps vitiated by the fact that in five
of the pelves he describes, gross bony contraction was present. He quotes
Elliot Smith and Wood Jones as saying that sex contradictions are not
uncommon in the individual parts of the pelvis and the evidence of any one
indication may at times be fallacious. In his opinion the application of
the term male pelvis to a high assimilation pelvis is misleading and erro-
neous. The only type of outlet contraction to which the term male pelvis
may be applied is the pelvis in which the ischio-pubic section of the pelvis is
male. The presence of male characters in the iliac portion of the os in-
nominatum is far more common than in the ischio-pubic section. A male
ilio-sacral section of the pelvis gives rise to a deformity of the brim alone
producing a marked diminution of the true conjugate diameter.
In considering the general problem of the characters of the male pelvis
we have seen that the shape of the sacro-sciatic notch is the outstanding
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REPORTS OF SOCIETIES
character in anatomical material. The shape of this notch is intimately
‘bound up with the shape of the articular facet on the sacrum and hence
with the general shape of the sacrum. For this reason the question of
sacral shape and direction must receive consideration in the determination
of what are to be regarded as masculine characters in a pelvis.
According to Derry, the main character of the male sacrum is the
presence of an articular facet on three instead of on two sacral vertebrae.
In the female, the sacrum retains its primitive backward direction, in the
male it becomes more vertical. In female sacra in which the male type
of articulation is noted, assimilation is the rule, i.e. there are six sacral
vertebrae. He considers that the result of this general resemblance to the
male type is to contract the male outlet, concluding by saying that the
assimilated sacrum in women is frequently associated with characters which
belong more commonly to the male. As yet it is not possible to decide
whether assimilation is to be regarded as a true male character. In passing
it would seem that the common attribution of the funnel pelvis to high
assimilation rests on inadequate evidence. In obstetrical X-ray material,
the presence of only four lumbar vertebrae is rare although six-pieced
sacra are common. The extra sacral vertebrae would appear usually to be
due to a low assimilation of the first coccygeal vertebra.
Evidently one of the most important male characters in the pelvis is the
sacral constitution and shape. Williams in his textbook, 1936, seventh
edition, refers to the male pelvis as funnel in type. It would be better I
think to speak of pelves of this type as instances of contracted outlet. This
would bring them in line with the ischio-pubic type of inversion described
by Hart.
It is clear from the foregoing brief review of the literature that the
position is as yet far from clear.
The present note is based on three recent cases.
(1) A primigravida was admitted to my ward after the forceps had failed
in a posterior position. I rotated the head with the forceps and extracted
a living male child, 8 pounds in weight. Extraction was difficult because of
contraction of the outlet, both antero-posterior and transverse diameters. The
external measurements of the pelvis were 10, 1034, 8 inches. The sacral a
promontory could not be felt. The iliac crests had the heavy rolled margin
of the male. The patient herself was tall and heavily built, she had pro-
nounced hirsutes and a general male distribution of hair. The menstrual
history had been normal. Lateral X-rays show (a) extension of the sacral
articular facet to the third sacral vertebra, (b) the presence of a long six-
piece sacrum due to low assimilation with a well-mrked false promontory
between the first and second sacral vertebrae. The posterior pelvis showed
some flattening of the posterior segment.
(2) A patient aged 31 years, was admitted to the hospital in 1932 as an
emergency case, She had been in labour for 81 hours. The vertex was ‘e
presenting with the occiput posterior. A manual rotation was performed
and a macerated child was extracted with difficulty. In 1937 she became
pregnant for the second time. She was a tall, heavily built woman, black
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
haired with hirsutes concealed by shaving, and a male distribution of hair.
Her menstrual history had been normal. The external pelvic measurements
were 814, 934, 7% inches. The promontory could not be felt. X-ray pelvi-
metry showed all the dimensions of the inlet to be the same, 4.2 inches,
the inlet was almost round, with a little flattening of the posterior segment.
Lateral films showed a female sacro-sciatic notch, the sacral curvature
increased and a high angle of inclination of the brim. The sacrum showed
low assimilation. The ilium was of the female type. The patient was
normally delivered of a living child, 9 pounds in weight, after six hours
in labour. Although inversion of the general sex characters was present and
the shape of the false pelvis was of the male type, the main if not the only
male character of the pelvis was the sacral shape and constitution.
(3) The third case was that of a primigravida of average stature aged
21 years. The external pelvic measurements were 9, 1014, 7% inches. The
sacral promontory could not be felt. The sacrum was unduly curved, the
outlet was narrow. The iliac crests had the curve and rolled edge of the
male pelvis. This patient too exhibited a general masculine appearance with
hirsutes and a male distribution of hair. X-rays of the pelvis showed the
brim to be circular. The sacrum articulated with the ilium by two and a
half pieces. Lateral views showed a high inclination of the brim and the
presence of a well-marked false promontory. The sacrum showed low assimi-
lation. The depth of the pelvis was increased. It was the presence of
hirsutes which drew my attention to the possibility of a pelvic malformation.
It would appear that many of the criteria applied by anatomists to
the sexual characters of the pelvis are unsatisfactory in clinical and radio-
logical practice and it might be best to restrict the term of masculine pelvis
to those cases in which the patients exhibit other evidences of mingling
of the sex characters. The work of Thompson, showing that the sex of
the pelvis is determined in utero has a bearing on this aspect of the problem.
The sexual development of the pelvis must be bound up with the develop-
ment of the whole secondary sex apparatus. The relation between the assi-
milation pelvis and the masculine pelvis is debatable, but it would appear
that low assimilation with a false promontory is a male feature. High
assimilation has been rare at all events in our material. Although measure-
ment of the sub-pubic angle should be of value, it is a measurement difficult
to make clinically or radiologically and while the significance of transverse
narrowing of the outlet must not be minimized it would appear that the
importance of antero-posterior contraction of the outlet or low pelvis has
not received the attention it deserves in my own limited experience.
All contractions at the outlet are rare and in most of them it is. the
antero-posterior flattening of the bony outlet and lower pelvis which has
given me most trouble. This as we have seen is one of the established
features of the so-called masculine pelvis and is essentially a function of the
shape of the sacrum.
This note has been written merely with the object of ventilating some
of the problems of the so-called male pelvis in the hope of eliciting the
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REPORTS OF SOCIETIES
views of the Society. The only specified conclusions one can make are as
follows :
(1) The diagnosis of android or male pelvis as a common pelvic type
cannot be made on examination of the brim alone and the classification of
Thoms, who does not admit it as a common type, is to be preferred to that
of Caldwell and Malloy.
(2) This type of pelvis should be looked for when there is other evidence
of sexual mingling.
(3) It is unlikely that only one section of the pelvis should present male
characters.
(4) Pelves of this type are responsible for some cases of persistent
occipito-posterior position.
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NORTH OF ENGLAND OBSTETRICAL AND GYNAECOLOGICAL
SOCIETY.
FEBRUARY
A meeting of the Society was held in Liverpool on Friday, February 25th,
1938.
Mr. FRANK STABLER described
Two CasEs OF ADVANCED EXTRA-UTERINE GESTATION.
(1) The first patient was a woman 30 years of age, pregnant for the
second time. Her first pregnancy terminated in normal delivery at term.
In this pregnancy delivery was expected about July 4th, 1936. On June 25th
she had recurrent abdominal pain for 14 hours, there was a blood-stained
discharge, and then the pains completely ceased. Some clots were passed
and since then the foetal movements had ceased. She was in hospital a fort-
night later, on July oth, very ill with a temperature of 102°F. and a pulse-
rate of 144; she was very toxic in appearance. A soft fluctuant mass reached
to the umbilicus, but the foetal position could not be identified with any
certainty. The pelvis was roomy, the os closed and some offensive bloody
discharge was being passed. On the supposition that the dead foetus was
intra-uterine, a full medicinal induction with castor oil, 30 gr. of quinine
sulphate and pituitrin was given, followed by hot douches. The only result
was that the patient became pulseless, very ill, and collapsed. After a week
the temperature settled, but the pulse-rate remained in the region of 140,
at times being uncountable. The patient became more and more toxic,
wasted and ill, whilst severe lower abdominal pain and sleeplessness added
to her misery. In the month after admission three medicinal inductions
and an intra-uterine douche had been given in an effort to induce labour
pains without avail. Pelvic cellulitis appeared filling the left side of the
pelvis. On August 9th, a month after admission, I was asked to undertake
treatment and I decided that the foetus was extra-uterine. The head
appeared to be in the left lumbar region, but apart from this I could not
distinguish the remainder of the foetus. I arranged to open the abdomen on
the following day, but was deterred and my diagnosis somewhat shaken by
a sudden discharge of stinking liquor amnii per vaginam. The patient passed
copious watery stools per rectum and faecal smelling liquor per orem uteri,
and the abdominal swelling diminished considerably. Four days later, how-
ever, I regained my confidence in the diagnosis, and owing to her deplorable
general condition, I decided that only local anaesthesia was permissible.
After an injection of a quarter of a grain of morphia and a seventy-fifth
of hyoscine, I infiltrated the anterior abdominal wall with 1 per cent solution
of novocain and opened suprapubically a cavity; I cannot give a better
description than the house surgeon’s. The cavity was filled with soft black
faeces (the patient had been having a mixture containing iron) which were
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REPORTS OF SOCIETIES
oozing quantities of foul gas. In the midst of the mass were the remains
of a macerated foetus which looked like a rabbit which had been left in a
ditch for a month. The skin was in rags over the protruding ribs, and
inside the cavity of the body were black rotten masses frothing with foetid
gas. The vertebral spines projected through the tattered skin. The bones
of the cranial vault were lying separate in the left upper portion of the
cavity. There was no evidence of cord or placenta. The upper limit of the
cavity was domed over by matted coils of small intestine, whilst the lower
was formed by the bladder, uterus and rectum. On the left side the
descending colon was laid open widely for four inches of its length, and below
an opening communicated with the cervix.
The foetal remains and faecal matter were cleared out of the cavity and
a large drainage tube left in. The patient’s response was immediate and
excellent. Her pain ceased, she slept and was able to eat, but now faeces
were passed from the wound, from the vagina and from the anus. The
cavity was kept washed out and it rapidly diminished in size until at the
end of the week it was only about 3 inches in diameter. The pulse-rate
remained fast, in the region of 140, but was stronger. Nine days after opera-
tion she began to vomit, the faecal discharge ceased and distension became
apparent. On the tenth day, under local anaesthesia, a fresh incision was
made and a loop of acutely obstructed jejunum was drained by a tied-in
catheter. She died of intestinal obstruction some hours later.
My surmise is that the placenta had to some extent been implanted on
the colon and had been entirely discharged with the cord in the faeces before
operation. The collapse of the cavity induced acute jejunal obstruction
and death.
My second case occurred fairly recently. The patient was an unmarried
primigravida, aged 25 years, referred to me at the thirty-sixth week of preg-
nancy. Examination showed the foetus to be lying transversely with the head
in the right lumbar region. The foetal parts and movements were unduly
easily palpable, while a smooth rounded mass, the size of a five months’
pregnancy, could be felt in the left inguinal region. There was considerable
hydramnios. Contractions could not be felt over the foetus or over the
smooth mass. Per vaginam there was a fluctuant bulging of the posterior
fornix and the cervix appeared to be connected with the abdominal mass
which subsequently proved to be the placenta, not the uterus.
I then went more deeply into her history and found that the last
menstrual period had begun on January 6th, 1937. On May 8th, 4 months
later, she had pain in the left lower abdomen-which kept her in bed for a
week. She returned to work on May 15th, but on May 2oth had sudden
intense pain and was in bed for two more weeks. She felt movements for
the first time at the end of May, and since. then the movements of the
child had caused her pain of increasing severity as pregnancy advanced.
X-ray pictures were taken and showed a normal foetus lying transversely;
an interesting point in the radiograph is the presence in front and to the
right of the first lumbar vertebra of an oval mottled shadow with a clearly
defined edge, half the size of the foetal head. I could not explain this.
It was first suggested that the foetus was intra-uterine in position and that
this was a calcified fibroid; this is unlikely at the age of 25 years; moreover,
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
I thought the foetus was extra-uterine. A second suggestion was that it
was a renal ca'culus; but it was too far forward in the lateral view for this.
Thirdly, it was suggested that the pregnancy was extra-uterine and the
shadow was that of calcified blood-clot or placenta. If this were so, the
placenta must be in a very dangerous and unusual site.
I was unable to solve the mystery at operation, but did so a day or
two later. The patient had intestinal obstruction and had been given large
quantities of bismuth. The radiograph was taken three days after she took
the last dose. A second radiograph after operation showed the shadow in
the rectum.
I must confess that for four days I did not realize that there was
genuine intestinal obstruction, for she had had vomiting throughout her
pregnancy from the fourth month, and I tried to improve her general
condition so that I might operate on her. This proved futile and she was
very ill when I decided to intervene. The pulse-rate was 150, she was
dehydrated, the urine was loaded with acetone, and she was in constant
pain. An interesting feature was the way she feared the movements of the
child, for every movement induced colicky pain which had been present
from the fourth month onwards, as if the kicking of the intestine by the
child induced peristalsis.
On September 18th, at 2 p.m., she was given a quarter of a grain of
morphine sulphate and a hundredth of a grain of hyoscine hydrobromide
hypodermically. At 2.40 p.m, a large Spencer-Wells forceps was passed
through the cervix for three inches and confirmed that there was not an
intra-uterine gestation. A mid-line sub-umbilical incision was made after
infiltrating the anterior abdominal wall with 1 per cent of procaine. The
upper 2 inches of the incision revealed thick wash-leather yellowish grey
amnion, and the incision was rapidly extended two more inches above the
umbilicus. On opening the membranes a large quantity of liquor, estimated
at 6 to 8 pints, escaped. The child was extracted as a breech and breathed
immediately. It was a female weighing 5 pounds 4 ounces and showed some
lateral flexion of its body and a mild right-sided calcaneo-valgus. Both
these were of a temporary nature, disappeared in 48 hours, and wou'd have
passed unnoticed in a normal delivery. The membranes were adhereni
above to distended small intestine to large intestine and to omentum, but
there was no evidence of a false sac: where it was possible to strip off the
membranes the naked adjacent structure was left beneath. In front the mem-
branes were applied to the anterior abdominal wall, and below they covered
the bladder and filled the pouch of Douglas, leaving the placenta projecting
up into the sac. By separating some omentum, access was gained to the
general peritoneal cavity, and it was found that the placenta was attached
solely to the left broad ligament, left ovary and left Fallopian tube close
to the uterine cornu. The outer half of the left Fallopian tube was outside
the sac and appeared normal. The uterus was surprisingly small, being as
large as it is at the second month of pregnancy. Removal of the placenta,
which contained a haematoma, the size of an egg, close to the cord on the
foetal aspect, was not difficult and needed but three clips: one clamped the
ovarian vessels, one the round ligament and one the ovarian ligament and
uterine cornu. Very little blood was lost, A little nitrous oxide and oxygen
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REPORTS OF SOCIETIES
were administered during the clamping of the pedicles. About half of the
membranes was removed by stripping, but it was found that this caused
some capillary oozing so the remainder on the bladder, bowel, pouch of
Douglas, omentum and anterior abdominal wall was left in situ and the
abdomen closed without drainage.
At the end of the operation the general condition was quite good, though
the pulse-rate was 170. She was returned to bed and a pint of 5 per cent
glucose in normal saline was slowly introduced intravenously.
On the following day there was a considerable degree of ileus. Five units
of posterior pituitary extract with eserine sulphate, gr. 1/1ooth, were given
‘hypodermically, followed by 5 more units after half an hour. Her bowels
moved at least eight times, and from then on she made a rapid recovery,
only delayed by the breaking down of a small area of the wound which
required three stitches. The temperature was never above normal, and by
the fourteenth day the pulse-rate was 80. She left hospital 5 weeks after
operation in good condition. The baby was fed artificially and after thriving
for a while developed enteritis.
I am sorry to have to add, however, that I have recently had a letter
from the mother to say that the baby was thriving and putting on weight,
but developed broncho-pneumonia and died at 5 months of age after an
illness lasting for only 3 days.
I have little to add in the way of comment on these cases. Live babies
from extra-uterine gestation are not really so uncommon as one might sup-
pose. In 1906 Sittner collected all the records he could back to the year
1809, and in 1935 Hellmana and Simon re-published Sittner’s list and added
those up to date. In the 126 years 300 odd cases of viable extra-uterine
gestations were recorded, but many of these were merely foettis of 20 weeks
which had a pulsating cord or some such evidence of life at birth. I have
rejected all of less than 28 weeks of development, leaving 266 cases in 126
years. Of 266 women 179 recovered, 84 died, and the fate of 3 is unknown.
Of the 266 babies 152 lived for 8 days or more, 113 died within this period
and the fate of one is unknown. In only 80 cases did mother and child
survive according to Hellman’s and Simon’s abstract, but I find that this
figure should be 110. The authors rejected some cases in which the child
died later, but as all of them will eventually die, I have adhered to the
standard of survival for the child for 8 days; 28 of the 266 babies are recorded
as being deformed to some extent, and of these 16 lived 8 days or more.
These figures are probably valueless as evidence of the likelihood of sur-
vival, for there is a greater tendency to record successful than unsuccessful
cases.
Since then Zarfl in 1935, Krishnna in 1936, Futh in 1936, Wilson in 1936,
Woods in 1936, and Anderson in 1936, have reported, cases.
I must emphasize how important it appears to me to use only local anaes-
thesia for these very ill patients.
“I set out on the second case determined to leave, if necessary, the whole
placenta in the abdomen and to close the wound in the ordinary way, for
I recollect a case in which a woman had had twins removed at the seventh
month from an extra-uterine gestation and the placenta left. Nine months
later, Mr. Harvey Evers opened the abdomen as a small fistula had appeared.
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There was no structure representing the placenta at all: merely a narrow
fistulous track about 3 inches in length. In the case I have recorded, re-
moval of the placenta was fortunately easy, but a great deal of the membranes
was left without any harm.
Discussion. In the discussion of Mr. Stabler’s cases Mr. St. GEORGE
WILson recounted a case in which a live foetus was obtained and showed
the X-ray photographs taken before cperation, In his case the placenta was
left in situ within the broad ligament.
Dr. J. W. Brive, of Manchester, stressed the value of X-ray examination
in these cases.
Mr. MarsHALL, of Liverpool, pointed out the advantages of local anaes-
thesia in these cases of poor surgical risk.
Mr. St. GEORGE WILSON described a case of
SARCOMA OF THE FEMUR ASSOCIATED WITH PREGNANCY.
Mrs. T., aged 30, was admitted to hospital complaining of pain, which
she described as ‘“‘hot, and like needles from the right thigh down to the
leg.”’
She was pregnant for the fourth time, but was uncertain as to the date
of onset; she believed she was then about 32 weeks pregnant.
The pain had been present throughout pregnancy, and a few days
previously her sister had remarked that the right thigh was somewhat
swollen.
On admission there was a slight swelling of the outer part of the right
thigh about the junction of the upper and middle thirds, and this was felt
to be due to an indefinite enlargement of the bone with thickening of the
surrounding muscles.
There was no tenderness.
The temperature and pulse-rate were normal.
The urine contained a trace of albumin, with a few hyaline casts, and
calcium oxalate crystals.
The Wassermann reaction was negative and the white cell count was
10,100 per cubic millimetre.
Pregnancy. The foetus was felt presenting by the vertex and was esti-
mated to be at the thirty-fourth week of gestation.
X-ray examination showed a swelling of the upper part of the shaft of
the femur with irregularity of the outline and a raising up of the periosteum.
Dr. R. E. Roberts was then of the opinion that the X-ray appearance
suggested that of Ewing’s sarcoma. It was then suggested that a biopsy
should be made to establish the differential diagnosis between neoplasm and
a chronic inflammatory lesion, On biopsy it was noted that the condition
was undoubtedly neoplastic, that the growth appeared encapsuled, was pene-
trating the periosteum, and was felt as a mushy mass in which spicules of
bone could be detected. .
Microscopic examination of fragments removed, both of soft growth and
a piece of invaded bone, showed the presence of a rather large round-celled
588
REPORTS OF SOCIETIES
sarcoma, the cells of which were invading bone and connective tissue, and
tended to be arranged in groups.
It was decided that the microscopic appearance supported the radiological]
diagnosis of Ewing’s sarcoma, and the treatment determined on was to
conserve the pregnancy, and the limb, and treat the neoplasm with deep
X-rays owing to the marked radiosensitivity of Ewing’s tumour.
It was argued that it was then too late to remove the limb.
Some delay in commencement of deep X-ray therapy was inevitable as
the skin incision of the biopsy had to heal, and the patient had to be trans-
ferred to another institution, where deep X-ray therapy was available.
When deep X-ray therapy was commenced some three weeks later it was
found that a pathological fracture had occurred.
A Thomas’s knee splint was applied to the limb and X-ray treatment was
continued until two weeks later when labour began; the membranes ruptured
spontaneously at the onset of labour. A living child, 7 pounds 2% ounces in
weight and 20 inches in length, was delivered by the breech.
The placenta appeared to be normal, and careful microscopical examina-
tion did not reveal the presence of any metastasis.
The condition of the leg became worse, the swelling increased, and the
pain was becoming intolerable.
Dr. R. E. Roberts was then of the opinion that the X-ray appearance
was that of an osteogenic sarcoma, and it was finally decided to amputate
the leg through the hip joint, in order to make the patient more comfort-
able rather than with any idea of cure, though radiological and clinical
examination did not yet reveal any metastasis in the chest.
Since the operation six weeks ago, the patient has had almost continuous
pyrexia, the cause of which has not been discovered.
‘A few references to sacroma of bones other than the pelvic bones are to
be found in the literature.
McCoogan, in a review of malignant disease associated with pregnancy,
relates a case of oestrogenic sarcoma of the femur which was known to be
present before pregnancy occurred, and was treated by X-rays both before
and after that. The bone showed marked decalcification.
Barnes reported a case of metastatic sarcoma in an ovary during preg-
nancy.
Vaille, quoted by McCoogan, reported a case, collected 17 cases from the
literature up to date, and stated that in 9 of these growth was rapid in the
puerperium.
The Specimen. Consists of the thigh which has been incised in the mid-
line in front, the incisional scar of the biopsy is on the other side, and the
femur has been sawn obliquely along its length.
The fracture and the growth extending along the medulla of the bone
can be seen. The soft friable growth is to be noted extending through the
surrounding muscles of the thigh as far as the deep fascia.
REFERENCES.
McCoogan, L. S. Surg. Gynecol. and Obstet., 1937, Ixv, 145.
Barnes, C. S. Amer. Journ. Obstet. and Gynecol., 1935, xxix, 734.
Vaille. Internat. Clinic., 1918, ii, 143.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Mr. C. J. K. Hamirton, of Liverpool, described two cases:
I. SIAMESE TWINS OBSTRUCTING LABOUR.
A patient, pregnant for the seventh time, was admitted to the hospital
as an emergency on account of post-maturity.
Her confinement was, at this time, one month overdue, the breech was
presenting and the child appeared to be large.
Quinine was given and the same day the foetal heart sounds became
inaudible. Labour commenced that day and was proceeding normally until
the second stage was reached when there was some delay which called for
interference.
Under general anaesthesia the breech was found to be high with one leg
prolapsed into the vagina. This was pulled down and found to be a left leg
with some deformity of the toes. A second leg was then easily pulled down
and was also found to be a left leg.
A diagnosis of twin pregnancy with both breeches presenting was then
made.
A more careful examination revealed the presence of a third leg and all
these legs appeared to be united to a common pelvic girdle of abnormal
character.
Embryotomy was then performed commencing by removing the three legs.
Great difficulty was experienced as the further the monster was brought
down the more wedged it became.
An attempt was made to pass the Blond-Heidler saw between the two
thoraces, but this was found to be impossible.
The common abdominal cavity was opened and evisceration was _ per-
formed. Unfortunately, in the stress of the moment a careful count was
not made of the number of livers, spleens, etc.
Finally, it was found impossible to decapitate one head, deliver the bodies,
and finally the decapitated head.
Examination afterwards showed that the posterior wall of the lower seg-
ment to be ruptured and subtotal hysterectomy was performed.
A blood transfusion was afterwards given and the patient was discharged
on her twenty-first day after delivery after a non-morbid puerperium.
Examination of the specimen showed it to be a lecanopagus tetrabrachius
et tripus.
2. A CASE OF PROLONGED COMA,
The patient was comatose on admission and no history was obtainable.
Her two previous pregnancies had been perfectly normal, the last having
been in 1927.
She had been attending her own doctor for oedema of the feet and
one week ago was found to have albuminuria, 7 grammes in Esbach’s tube.
The day before admission the Esbach reading had been 3 grammes.
She had become drowsy the day before admission and had passed only
I ounce of urine in the 24 hours before admission.
On examination she was comatose and there was marked generalized
oedema. The blood-pressure was 222/130 millimetres Hg.
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REPORTS OF SOCIETIES
There was slight twitching of the right arm. All reflexes were brisk.
There was ankle clonus of the right leg and a bilateral extensor response.
The pupils were equal and reacted to light.
The uterus corresponded to a pregnancy of 28 weeks; the foetal heart
sounds were present.
A small amount of urine was obtained by catheter and was found, on
boiling, to be solid with albumin; neither sugar nor acetone was present.
Venesection was performed and three-quarters of a pint were withdrawn.
The colon was washed out, the result being a good coloured one. The cerebro-
spinal fluid was clear and was not under tension. /
Her condition was unchanged at midnight when the membranes were rup-
tured artificially; 0.5 cubic centimetre of veratrone was given which lowered
the systolic blood-pressure from 230 to 180. Intravenous drip saline was
commenced, using a 10 per cent solution of glucose. One ounce of urine was
passed in the first 24 hours.
On the morning of the 30th December for the first time the patient took
a small amount of fluid by mouth. Later on, as delivery did not seem
imminent, a balloon was introduced inte the uterus, and.some 4 hours later
a macerated foetus weighing 2 pounds 2 ounces was delivered.
The general condition improved after this, and the secretion of urine
increased enormously.
It was not until the rst January, 4 days after admission, that she made
an attempt to talk; towards the evening of that day she spoke rationally,
although she was still rather dazed.
The signs in the central nervous system had by this time completely
disappeared. The discs were reported to be normal by Dr. Bickerton.
Convalescence after this was uneventful. On discharge the systolic blood-
pressure was 200 millimetres Hg. with a trace of albumin in the urine.
When examined one week ago there was no albumin in the urine and the
patient looked very well. Her blood-pressure was 230/160 millimetres Hg.
Dr. A. A. GEMMELL described a case of
An UNUSUAL MALFORMATION OF THE VAGINA
(to be published in the Journal of Obstetrics and Gynaecology of the British
Empire).
Dr. C. Rickarps, of Manchester, read a paper entitled
UTERINE RUPTURE FOLLOWING CAESAREAN SECTION.
The speaker divided the cases into the four following groups:
Group I. The rupture occurs through an old incision in the upper uterine
segment and the placenta is situated away from the uterine scar. This is a
common type. The splits are often only discovered at operation.
The characteristics of cases in Group I are: (1) Rupture tends to occur
during labour. (2) Little or no haemorrhage occurs. (3) The pains become
niggling in type after the scar has started to give way. This is not invariable.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
(4) The bulging bag of membranes may sometimes be palpated through the
scar. (5) The prognosis is good provided that suitable treatment be avail-
able.
Group II. The rupture occurs through an upper segment incision and
the placenta is situated underneath the old scar.
This type is more serious. When the placenta is situated underneath the
old scar a gradual erosion of fibrous tissue by the placental villi occurs. This
erosion is an insidious one and may be associated with vague pains in the
lower abdomen. Haemorrhage into the abdominal cavity is much more likely
in this type.
The characteristics of cases in Group II are: (1) Gradual rupture tends to
occur towards the end of pregnancy. This may be accompanied by vague
pain in the lower abdomen, Such pain therefore should never, be ignored.
(2) After the onset of labour haemorrhage occurs and may be of considerable
severity. (3) The prognosis will not be so favourable as in Group I and will
depend very largely on the amount of intra-abdominal haemorrhage.
Group III. The rupture occurs after a previous lower segment Caesarean
section.
The incidence of rupture is said to be reduced by using the lower segment
technique. Trillat considers that these ruptures usually take place during
labour and there is an absence of pain.
The characteristics of Group III are: (1) The rupture is said to occur
during labour. There is no very convincing evidence on this point.
(2) Haemorrhage may occur due to the extension of the laceration laterally
into the uterine arteries. (3) Rarely the bladder may be involved giving rise
to haematuria.
Group IV. Rupture is complete, through an upper segment incision, and
the child, with its bag of membranes, is expelled into the abdominal cavity,
the placenta remaining in situ.
The physical signs are characteristic. The uterus is felt pushed over to
one side and the child, floating in the abdominal cavity, is very easily
palpable.
The characteristics of Group IV are: (1) The foetal heart sounds usually
cease. (2) The foetal movements usually stop. (3) The uterus is pushed
over to one side. (4) The foetus, lying free in the abdominal cavity, is
easily palpable.
Group V. The rupture is complete, through an upper segment incision,
and the child with its placenta is extruded in toto into the abdominal cavity.
Potter stresses that the most dangerous cases from the prognostic point of
view belong to this group and says that this type is usually associated with
severe haemorrhage and collapse and often results in the death of both
mother and child.
The characteristics of cases in Group V are: (1) The rupture is often
associated with severe abdominal haemorrhage. (2) The foetal heart sounds
are absent. (3) Foetal movements are absent. (4) The uterus is pushed
over to one side. (5) The foetus, lying free in the abdominal cavity, is easily
palpable.
Discussion. The PRESIDENT referred to the difficulty in classifying these
cases into definite groups and considered that one type might be merely a
later stage of another type. He referred to 17 cases of rupture of the scar
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REPORTS OF SOCIETIES
in the uterus which had been treated in the Jessop Hospital between the
years 1911 and 1937. In only 5 of these cases was the placenta proved to be
situated over the scar and in 2 cases rupture followed previous lower seg-
ment Caesarean section. He considered that rupture of the uterus does not
occur in more than 2 per cent of cases following Caesarean section.
Professor FARQUHAR Murray pointed out the necessity for excising the
edges of the scar before re-suturing. He considered that the erosive properties
of the placenta play a part in producing rupture of the scar.
_ Dr. J. E. Stacey pointed out that erosion by the placenta is unlikely to
take place if the scar is in the lower segment and thought that rupture of
lower segment scars indicated that the original incision had encroached or
the upper segment of the uterus.
Mr. FRANK STABLER said that the generally accepted figure of 4 per cent
as being the incidence of rupture of the scar after Caesarean section is too
high and considered that it was about 1.9 per cent, He did not believe that
erosion by the chorionic villi played any part in the aetiology of the con-
dition.
Mr. St. GEORGE WILSON mentioned 6 cases, in 5 of which the placenta had
been situated over the scar. He considered that if the foetus is completely
expelled into the abdominal cavity there is less likelihood of severe haemor-
thage, but the patient suffers from more shock.
Dr. C. WaLsH thought the grouping suggested by Dr. Rickards was arti-
ficial and that they should be divided into two groups according to the clinica]
signs, namely (1) silent, (2) classical.
Mr. C. MARSHALL pointed out that the incidence of rupture of the scar
after lower segment Caesarean section was no higher than 0.3 per cent and
that there had been no case recorded in which a transverse incision had
been followed by rupture with the exception of the one mentioned by the
President in the discussion.
Professor MILEs Puivipps thought that the grouping suggested was incom-
plete in that it did not include those cases in which the baby was delivered
through the vagina, but the placenta passed through the rupture into the
abdomen.
593
THE EDINBURGH OBSTETRICAL SOCIETY
At a meeting of the above Society, held on 12th January, 1938, with
the President, Professor JAMEs HENDRY, in the chair, Mr. HuGH MILLER, of
Inverness, reported
A CASE OF UNRUPTURED TUBAL PREGNANCY CONTINUING TO TERM.
Mr. Hugh Miller commented on the extreme rarity of pregnancy within
a Fallopian tube continuing to term, and referred to three such cases
reported in recent years. In considering this condition the differential
diagnosis lay between primary abdominal pregnancy, secondary abdominal
pregnancy, ovarian pregnancy and pregnancy in a rudimentary uterine
horn; these varieties of ectopic pregnancy advancing to a late stage ol
gestation were briefly reviewed. He then gave an account of the case he
had dealt with. The patient was aged 23 years; she became pregnant for
second time, had gone to some one to have abortion procured, but three
attempts were unsuccessful and gestation continued. The course of the
pregnancy was attended by pain in the lower abdomen and right iliac
fossa, frequency of micturition, fainting attacks and general ill-health. The
other signs, namely amenorrhoea, enlargement of the abdomen, recognition
of foetal life, and the X-ray appearances, were similar to those of a normal
pregnancy. Death of the foetus followed by a false labour took place at the
fortieth week. An abdominal operation was performed eight weeks later,
and the gestation sac was found to be hugely distended and thinned-out
right Fallopian tube firmly adherent to the back of the uterus; this sac
was removed unruptured with the body of the uterus and the left ap-
pendages.
The specimen, microscopical sections and the X-ray photographs were
demonstrated. The foetus, presenting by the breech, weighed 434 pounds,
and was 21% inches in length. There was slight distortion of the vertex
of the skull apparently due to its position, and a right talipes equino-varus
probably due to the same cause, but otherwise it was well developed and
fully mature. Chronic infection of the tubes with plical adhesions was
present, which suggested the cause of the fertilized ovum’s failing to pass
into the uterus. The nature of the pregnancy had been unrecognized, but
it might have been diagnosed earlier if more reliance had been placed on
the history of attempts to procure abortion being followed by continuance
of the pregnancy; on the painful symptoms accompanying the course of the
pregnancy; and possibly if X-ray examination by means of hystero-salpingo-
graphy had been employed. The subsequent progress of the patient was
994
REPORTS OF SOCIETIES
complicated by the occurrence, three weeks after the operation, of a urinary
fistula between the lower end of the right ureter and the stump of the
cervix, this position of the fisula and the fact that there was a very poorly
functioning right kidney being ascertained by retrograde and intravenous
pyelography. The treatment adopted was right nephrectomy, after which
the patient made an uninterrupted recovery.
At the same meeting Dr. G. DouGLas MATTHEW read a paper on
THE TREATMENT OF CHRONIC CERVICITIS.
Dr. Matthew said that some degree of cervical laceration was a common
accompaniment of labour, whether spontaneous or instrumental, and this
predisposed to cervical infection which, in its chronic form, was character-
istically seen in the multiparous patient with a history dating from a
previous confinement. While the majority of cases arose in this way, other
cases of cervicitis followed abortion, instrumental trauma or gonococcal
infection. Cervicitis led to much suffering, discomfort and ill-health, and
the outstanding symptoms were discharge, pain and menstrual irregularity.
In some cases urinary symptoms might result from vesical irritation or
involvement by actual infection, while in others the cervix might act as
a focus of infection in co-existent systemic disease. There was a very
definite connexion between chronic infection and carcinoma of the cervix.
Dr. Matthew considered that some sort of classification of cases of
cervicitis would be of assistance in the selection of treatment suitable for
individual cases. He suggested that cases could be placed in one of the
following four groups, (1) superficial cervicitis, (2) endocervicitis with erosion,
(3) endocervicitis, (4) diffuse cervicitis. He gave a short clinical description
of each of those types.
In coming to the question of treatment Dr. Matthew pointed out that
the aim of such therapy was completely to eradicate all infection and repair
laceration and eversion; the final result must be a smooth, supple cervix
with a patent canal. He dealt with several forms of treatment advocated
by various gynaecologists under the following headings, (1) conservative
treatment either by vaginal douching, local application of antiseptics or
caustics, insulin or ionization; (2) thermal treatment either by cauterization,
electrical coagulation or excision by diathermy; (3) radium; and (4) surgery.
He referred briefly to the possible complications resulting from these forms
of treatment.
Dr. Matthew had had the opportunity of using many of these methods
in the treatment of patients under the care of Professor Johnstone in the
wards of the Royal Infirmary during the past two years. From the results
obtained in those cases and from a consideration of other methods, he had
arrived at certain conclusions as to the best form of therapy to be used in
each of the four types of cervicitis which he had described. In superficial
cervicitis he recommended superficial electrical coagulation without dilatation
of the cervix and carried out in the out-patient department. In cases of
595
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
endocervicitis with erosion he advocated excision of the affected tissues by
the cutting current diathermy curette after full dilatation of the cervix.
This treatment should be carried out under anaesthesia in hospital. Bourne’s
zinc chloride method might be the ideal treatment for cases of pure endo-
cervicitis, while diffuse cervicitis was best treated by surgical excision and
repair of the cervix or amputation in older patients in whom subsequent
pregnancy was unlikely.
He concluded by referring to the treatment of cases during the post-natal
period and mentioned excellent results which had been obtained at the Royal
Maternity Hospital with electro-cauterization six to eight weeks after
delivery. He believed that as this post-natal treatment became more uni-
versally adopted, the number of patients attending gynaecological out-patient
clinics with symptoms of chronic cervicitis would gradually diminish in
number.
596
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